Provider Demographics
NPI:1790851996
Name:BLOOM, ILENE S (PAC)
Entity Type:Individual
Prefix:MS
First Name:ILENE
Middle Name:S
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:116 DEFENSE HWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7027
Mailing Address - Country:US
Mailing Address - Phone:410-897-9841
Mailing Address - Fax:410-897-9852
Practice Address - Street 1:116 DEFENSE HWY
Practice Address - Street 2:SUITE 400
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7027
Practice Address - Country:US
Practice Address - Phone:410-897-9841
Practice Address - Fax:410-897-9852
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC01316363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC001316OtherSTATE LICENSE
P90674Medicare UPIN