Provider Demographics
NPI:1093708570
Name:BLOOM, BRIAN P (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 UNION DEPOSIT RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-2910
Mailing Address - Country:US
Mailing Address - Phone:717-652-6105
Mailing Address - Fax:717-652-2165
Practice Address - Street 1:4520 UNION DEPOSIT RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2910
Practice Address - Country:US
Practice Address - Phone:717-652-6105
Practice Address - Fax:717-652-8152
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD06226L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA300084078OtherRAILROAD MEDICARE
PA0016867280014Medicaid
PA0016867280011Medicaid
PA0016867280001Medicaid
PA0016867280002Medicaid
PA0016867280015Medicaid
PA005631YGLTMedicare PIN
PA005631PQLMedicare PIN
PA005631FJDMedicare PIN
PA300084078OtherRAILROAD MEDICARE
PA0016867280011Medicaid
PA0016867280001Medicaid
PA005631H96Medicare PIN