Provider Demographics
NPI:1316197361
Name:MAX BLOOM RPT PA
Entity Type:Organization
Organization Name:MAX BLOOM RPT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:SHARON
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-788-0505
Mailing Address - Street 1:583 FREDERICK RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-4697
Mailing Address - Country:US
Mailing Address - Phone:410-788-0505
Mailing Address - Fax:
Practice Address - Street 1:583 FREDERICK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-4697
Practice Address - Country:US
Practice Address - Phone:410-788-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10280261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy