Provider Demographics
NPI:1639173255
Name:MOELLER-BLOOM, BERNICE (NP)
Entity Type:Individual
Prefix:MRS
First Name:BERNICE
Middle Name:
Last Name:MOELLER-BLOOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MYRTLE STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1093
Mailing Address - Country:US
Mailing Address - Phone:518-587-2400
Mailing Address - Fax:518-581-0141
Practice Address - Street 1:59 MYRTLE STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1093
Practice Address - Country:US
Practice Address - Phone:518-587-2400
Practice Address - Fax:518-581-0141
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3600631363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY350498OtherMVP