Provider Demographics
NPI:1457326324
Name:BLOOM, PATRICIA JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:JEAN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3263
Mailing Address - Country:US
Mailing Address - Phone:847-685-9900
Mailing Address - Fax:847-685-6390
Practice Address - Street 1:444 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3263
Practice Address - Country:US
Practice Address - Phone:847-685-9900
Practice Address - Fax:847-685-6390
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
013547Medicare UPIN
203587Medicare ID - Type Unspecified