Provider Demographics
NPI:1770530750
Name:BLOOM, JOSHUA A (MD)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:A
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 1:6308 8TH AVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-653-5360
Mailing Address - Fax:262-653-5357
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:SUITE 2000
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-653-5360
Practice Address - Fax:262-653-5357
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29321207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31437500Medicaid
WI110105435OtherMEDICARE RR
WI002532250Medicare PIN
WI110105435OtherMEDICARE RR