Provider Demographics
NPI:1265478473
Name:BLOOMQUIST, MICHAEL LEONARD (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEONARD
Last Name:BLOOMQUIST
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:2312 SOUTH 6TH STREET, SUITE F256 / 2B WEST
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454
Mailing Address - Country:US
Mailing Address - Phone:612-273-9800
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:2312 SOUTH 6TH STREET, SUITE F256 / 2B WEST
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-273-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 1196103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN768028OtherARAZ
MN9G743BLOtherBCBS
MN112423OtherUCARE
MN61-39497OtherMEDICA CHOICE & PRIMARY
MNC626OtherCHAMPUS/TRIWEST
MN0920001OtherPREFERRED ONE
MNHP29376OtherHEALTHPARTNERS
MN9G743BLOtherBCBS