Provider Demographics
NPI:1437135092
Name:GOLDBLOOM, ELLIE P (MD)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:P
Last Name:GOLDBLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CROSSROADS DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5441
Mailing Address - Country:US
Mailing Address - Phone:410-998-9100
Mailing Address - Fax:410-998-9104
Practice Address - Street 1:21 CROSSROADS DR
Practice Address - Street 2:SUITE 400
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5441
Practice Address - Country:US
Practice Address - Phone:410-998-9100
Practice Address - Fax:410-998-9104
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD654003100Medicaid
MDP00759902OtherR/R MEDICARE PIN
MDC31152OtherR/R MEDICARE GROUP PIN
MD156606Medicare PIN
MD654003100Medicaid
MDC31152OtherR/R MEDICARE GROUP PIN
MDKP2726DDMedicare ID - Type Unspecified