Provider Demographics
NPI:1952340788
Name:WILLIAM A BLOOM MD LLC
Entity type:Organization
Organization Name:WILLIAM A BLOOM MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-643-8561
Mailing Address - Street 1:654 MARILYN DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-4730
Mailing Address - Country:US
Mailing Address - Phone:985-626-4108
Mailing Address - Fax:985-649-7573
Practice Address - Street 1:105 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 305
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5539
Practice Address - Country:US
Practice Address - Phone:985-643-8561
Practice Address - Fax:985-649-7573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA24377OtherBLUE CROSS BLUE SHIELD
LA1365718Medicaid
B60268Medicare UPIN
LA24377OtherBLUE CROSS BLUE SHIELD