Provider Demographics
NPI:1679649370
Name:BLOOMFIELD, JAY (PT)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:BLOOMFIELD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 E GREENWAY RD
Mailing Address - Street 2:#106
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4648
Mailing Address - Country:US
Mailing Address - Phone:602-652-1112
Mailing Address - Fax:602-652-1114
Practice Address - Street 1:3602 E GREENWAY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4648
Practice Address - Country:US
Practice Address - Phone:602-652-1112
Practice Address - Fax:602-652-1114
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19552251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ116453Medicare PIN
AZZ116449Medicare PIN