Provider Demographics
NPI:1407096092
Name:BROOKE ALEXANDER-BLOOM D.O A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BROOKE ALEXANDER-BLOOM D.O A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-644-2323
Mailing Address - Street 1:PO BOX 15756
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-5756
Mailing Address - Country:US
Mailing Address - Phone:949-574-4600
Mailing Address - Fax:949-574-4680
Practice Address - Street 1:1401 AVOCADO AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7720
Practice Address - Country:US
Practice Address - Phone:949-644-2323
Practice Address - Fax:949-644-1840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACK859AMedicare PIN