Provider Demographics
NPI:1841207149
Name:BLOOM, REBECCA A (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:A
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1145 S UTICA AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-6863
Mailing Address - Fax:918-579-6869
Practice Address - Street 1:1145 S UTICA AVE
Practice Address - Street 2:STE 110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-579-6863
Practice Address - Fax:918-579-6869
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-12-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2004015684207P00000X
OK26032207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO243419306Medicaid
OK200080180AOtherMEDICAID
MO243419306Medicaid