Provider Demographics
NPI:1164403580
Name:BLOOM, BRIAN B (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:B
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 1:150 YORK STREET
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-4827
Mailing Address - Country:US
Mailing Address - Phone:781-297-6782
Mailing Address - Fax:781-297-1338
Practice Address - Street 1:150 YORK STREET
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-4827
Practice Address - Country:US
Practice Address - Phone:781-297-6782
Practice Address - Fax:781-297-1338
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75268207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3105164Medicaid
F49435Medicare UPIN
MA3105164Medicaid