Provider Demographics
NPI:1477536068
Name:BLOOM, KENNETH EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWARD
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CENTRAL PARK S APT 107
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1449
Mailing Address - Country:US
Mailing Address - Phone:212-262-2500
Mailing Address - Fax:212-765-3210
Practice Address - Street 1:1455 WEST AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-7304
Practice Address - Country:US
Practice Address - Phone:718-239-1500
Practice Address - Fax:212-765-3210
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169466207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04134401Medicaid
WI317621001Medicaid
E46363Medicare UPIN
1081792OtherSELECT CARE
E46363Medicare UPIN
MN070000752Medicare ID - Type Unspecified
030484964OtherCOMMERCIAL - FED TAX ID
HP19461OtherHEALTH PARTNERS
0328611OtherMEDICA
2M742BLOtherBLUE CROSS BLUE SHIELD
960421000321OtherPREFERRED ONE
WI317621001Medicaid
MN100324OtherUCARE
WI317621001Medicaid
MN100324OtherUCARE