Provider Demographics
NPI:1457432171
Name:BLOOM, SCOTT PHILLIP
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:PHILLIP
Last Name:BLOOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 N BROADWAY STE 307
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2109
Mailing Address - Country:US
Mailing Address - Phone:516-835-4092
Mailing Address - Fax:
Practice Address - Street 1:380 N BROADWAY STE 307
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2109
Practice Address - Country:US
Practice Address - Phone:516-835-4092
Practice Address - Fax:516-338-2901
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07E101Medicare ID - Type Unspecified
A60287Medicare UPIN