Provider Demographics
NPI:1841247228
Name:BLOOM, ALIDA M (RN, CS, FNP)
Entity type:Individual
Prefix:
First Name:ALIDA
Middle Name:M
Last Name:BLOOM
Suffix:
Gender:F
Credentials:RN, CS, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4024
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4024
Mailing Address - Country:US
Mailing Address - Phone:417-885-3888
Mailing Address - Fax:417-881-7638
Practice Address - Street 1:2900 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3634
Practice Address - Country:US
Practice Address - Phone:417-885-3888
Practice Address - Fax:417-881-7638
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO089317163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO177827OtherANTHEM BLUE CROSS/SHIELD
MOP01996OtherUSPS (W/C)
MO12432OtherCOX HEALTH PLANS UPI
MO1602599OtherUNITED HEALTHCARE
MO502277007Medicaid
MO142580001Medicare PIN
MO1602599OtherUNITED HEALTHCARE
MO12432OtherCOX HEALTH PLANS UPI