Provider Demographics
NPI:1376502377
Name:BLOOM, MARC WARREN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:WARREN
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:KINTNERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18930-9637
Mailing Address - Country:US
Mailing Address - Phone:610-847-9936
Mailing Address - Fax:
Practice Address - Street 1:8794 EASTON RD
Practice Address - Street 2:
Practice Address - City:OTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18942-9669
Practice Address - Country:US
Practice Address - Phone:610-847-9936
Practice Address - Fax:610-847-9936
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002902L111NS0005X, 111NR0400X
MT1079111NR0400X, 111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000089742OtherHIGHMARK BLUE SHIELD ID
PA0023261000OtherBLUE CROSS HMO ID
PA0023261000OtherBLUE CROSS HMO ID