Provider Demographics
NPI:1619993920
Name:BLOOMBERG, GORDON R (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:R
Last Name:BLOOMBERG
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 1:1 CHILDRENS PL
Mailing Address - Street 2:C B 8116
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-2694
Mailing Address - Fax:314-454-2515
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:STE 5S30
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-2694
Practice Address - Fax:314-454-2515
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR24062080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1737758Medicaid
MO103810076Medicaid
IL$$$$$$$$$Medicaid
MO103810076Medicare PIN