Provider Demographics
NPI:1740397819
Name:ROSENBLOOM, PHILIP M (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:M
Last Name:ROSENBLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 AUDUBON PLAZA DR STE 230
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1319
Mailing Address - Country:US
Mailing Address - Phone:502-636-0574
Mailing Address - Fax:502-636-0579
Practice Address - Street 1:3 AUDUBON PLAZA DR STE 230
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1319
Practice Address - Country:US
Practice Address - Phone:502-636-0574
Practice Address - Fax:502-636-0579
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY16942208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64169428Medicaid
1312401Medicare ID - Type Unspecified
KY64169428Medicaid