Provider Demographics
NPI:1215053624
Name:BLOOM, MATTHEW N (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:N
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4265
Mailing Address - Country:US
Mailing Address - Phone:253-596-3300
Mailing Address - Fax:
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000351632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8209454Medicaid
WAP00731107OtherMEDICARE RAIL ROAD
WA8209454Medicaid
WAGAB22557Medicare PIN
WAG8871265Medicare PIN
WAGAB22485Medicare PIN
WAP00731107OtherMEDICARE RAIL ROAD