Provider Demographics
NPI:1104822881
Name:BLOOM, FRED A (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:A
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 1:67 JOURNEY'S END RD.
Mailing Address - Street 2:
Mailing Address - City:MT. VERNON
Mailing Address - State:ME
Mailing Address - Zip Code:04352
Mailing Address - Country:US
Mailing Address - Phone:207-873-1636
Mailing Address - Fax:
Practice Address - Street 1:67 SILVER STREET
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901
Practice Address - Country:US
Practice Address - Phone:207-873-1636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0076732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME012882Medicare ID - Type Unspecified