Provider Demographics
NPI:1780891200
Name:BLOOM, PETER MARK (MS)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:MARK
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:PUTNAM VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10579-1314
Mailing Address - Country:US
Mailing Address - Phone:914-220-2710
Mailing Address - Fax:
Practice Address - Street 1:366 LAKE SHORE RD
Practice Address - Street 2:
Practice Address - City:PUTNAM VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10579-1314
Practice Address - Country:US
Practice Address - Phone:914-220-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008016225100000X
NY011791225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQA3941Medicare ID - Type UnspecifiedNON-PARTICIPATING