Provider Demographics
NPI:1093788028
Name:BLOOM, KAREN K (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:K
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 RIVER HILL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-1193
Mailing Address - Country:US
Mailing Address - Phone:502-645-1043
Mailing Address - Fax:815-550-2223
Practice Address - Street 1:18 RIVER HILL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-1193
Practice Address - Country:US
Practice Address - Phone:502-645-1043
Practice Address - Fax:815-550-2223
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY26931208100000X
IN01037987A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64269319Medicaid
KY000000048653OtherANTHEM PROVIDER NUMBER
IN100028010Medicaid
KY0078112Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
KYE13515Medicare UPIN
IN100028010Medicaid