Provider Demographics
NPI:1356475594
Name:BLOOMSTEIN, JERRY M (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:M
Last Name:BLOOMSTEIN
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 1:1774 N 84TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2817
Mailing Address - Country:US
Mailing Address - Phone:414-475-7118
Mailing Address - Fax:
Practice Address - Street 1:1220 DEWEY AVE
Practice Address - Street 2:BLDG 2
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2504
Practice Address - Country:US
Practice Address - Phone:414-454-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI288172084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31465900Medicaid
WIF54421Medicare UPIN