Provider Demographics
NPI:1992005326
Name:BLOOM, ALISA CAROLE (MPH, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:CAROLE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MPH, RDN, LDN
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:
Other - Last Name:LEVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1020 MILWAUKEE AVE
Mailing Address - Street 2:SUITE 341
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3513
Mailing Address - Country:US
Mailing Address - Phone:773-951-5557
Mailing Address - Fax:847-941-0559
Practice Address - Street 1:1020 MILWAUKEE AVE
Practice Address - Street 2:SUITE 341
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-3513
Practice Address - Country:US
Practice Address - Phone:773-951-5557
Practice Address - Fax:847-941-0559
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
164-004502133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7942001Medicare PIN
IL7942Medicare PIN