Provider Demographics
NPI:1073610390
Name:BLOOMQUIST, ERIN L (PT)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:L
Last Name:BLOOMQUIST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 NORTHLAND DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1041
Mailing Address - Country:US
Mailing Address - Phone:616-884-5827
Mailing Address - Fax:616-884-5828
Practice Address - Street 1:251 NORTHLAND DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1041
Practice Address - Country:US
Practice Address - Phone:616-884-5827
Practice Address - Fax:616-884-5828
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7977001Medicare UPIN
MIEB008415Medicare UPIN