Provider Demographics
NPI:1144451311
Name:BLOSSOMWOOD MEDICAL PC
Entity type:Organization
Organization Name:BLOSSOMWOOD MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VYTAUTAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PUKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-431-9257
Mailing Address - Street 1:2121 WHITESBURG DR SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4501
Mailing Address - Country:US
Mailing Address - Phone:256-883-0107
Mailing Address - Fax:256-883-0207
Practice Address - Street 1:2121 WHITESBURG DR SE
Practice Address - Street 2:SUITE C
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4501
Practice Address - Country:US
Practice Address - Phone:256-883-0107
Practice Address - Fax:256-883-0207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD29689207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL113285Medicaid
AL102G114374Medicare PIN