Provider Demographics
NPI:1700851011
Name:LINDBLOOM, BRENT J (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:J
Last Name:LINDBLOOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5201
Mailing Address - Fax:605-945-5094
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-945-5201
Practice Address - Fax:605-945-5094
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1783207V00000X
SDSD1783207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6200540Medicaid
SD6200543Medicaid
SD6200540Medicaid
SD6200543Medicaid
SDE25403Medicare UPIN