Provider Demographics
NPI:1578676359
Name:BLOOM, BENJAMIN HARRIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:HARRIS
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 PENN BLVD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-1416
Mailing Address - Country:US
Mailing Address - Phone:215-849-0422
Mailing Address - Fax:215-849-1741
Practice Address - Street 1:2 PENN BLVD
Practice Address - Street 2:SUITE 117
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-1416
Practice Address - Country:US
Practice Address - Phone:215-849-0422
Practice Address - Fax:215-849-1741
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-024324-E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000915192-0007Medicaid
PAC32590Medicare UPIN
PA165950Medicare ID - Type Unspecified