Provider Demographics
NPI:1003085762
Name:SANFORD BLOOMBERG MD PC
Entity Type:Organization
Organization Name:SANFORD BLOOMBERG MD PC
Other - Org Name:SANFORD BLOOMBERG MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PC PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-584-1402
Mailing Address - Street 1:112 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060
Mailing Address - Country:US
Mailing Address - Phone:413-584-1402
Mailing Address - Fax:413-585-1565
Practice Address - Street 1:16 CENTER STREET
Practice Address - Street 2:ROOM 226
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060
Practice Address - Country:US
Practice Address - Phone:413-584-1402
Practice Address - Fax:413-585-1565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANFORD BLOOMBERG MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA314432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MASAM13765Medicaid
MAA55304Medicare UPIN
MABLG14089Medicare PIN