Provider Demographics
NPI:1598758161
Name:DAVID L BLOOM PA
Entity Type:Organization
Organization Name:DAVID L BLOOM PA
Other - Org Name:COLONNADE IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-707-1100
Mailing Address - Street 1:1430 SPRING HILL RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3000
Mailing Address - Country:US
Mailing Address - Phone:703-287-4189
Mailing Address - Fax:703-448-1807
Practice Address - Street 1:100 FULFORD AVE
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3812
Practice Address - Country:US
Practice Address - Phone:888-440-6494
Practice Address - Fax:410-838-7895
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVID L BLOOM PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH307Medicare PIN