Provider Demographics
NPI:1295824530
Name:SCOTT BLOOM MD PC
Entity Type:Organization
Organization Name:SCOTT BLOOM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-338-2900
Mailing Address - Street 1:380 N BROADWAY STE 307
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2109
Mailing Address - Country:US
Mailing Address - Phone:516-835-4092
Mailing Address - Fax:516-338-2901
Practice Address - Street 1:99 JERICHO TPKE
Practice Address - Street 2:SUITE 206
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-1073
Practice Address - Country:US
Practice Address - Phone:516-338-2900
Practice Address - Fax:516-338-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A60287Medicare UPIN
07E101Medicare ID - Type Unspecified