Provider Demographics
NPI:1326039181
Name:BLOOMINGDALE, KERRY L (MD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:L
Last Name:BLOOMINGDALE
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:PO BOX 260
Mailing Address - Street 2:
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-0260
Mailing Address - Country:US
Mailing Address - Phone:508-898-8650
Mailing Address - Fax:508-870-9793
Practice Address - Street 1:1132 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3878
Practice Address - Country:US
Practice Address - Phone:800-378-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA437932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA15-00675OtherEVERCARE
MA719405OtherTUFTS MEDICARE PREFERRED
MAC04856OtherBC/BS OF MASSACHUSETTS
MAC04856OtherFEDERAL BC/BS
MA719405OtherTUFTS
MAO167959Medicaid
MAC04856OtherBLUE CARD
MA15-00675OtherEVERCARE
MA719405OtherTUFTS