Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 1079 | MT |
N | 111NR0400X | Rehabilitation Chiropractor | 1079 | MT |
Y | 111NR0400X | Rehabilitation Chiropractor | DC002902L | PA |
N | 111NS0005X | Chiropractic Sports Physician | 1079 | MT |
N | 111NS0005X | Chiropractic Sports Physician | DC002902L | PA |
NPI | 1376502377 |
---|---|
Provider Name | Dr. Marc Warren Bloom |
First Address | Kintnersville, PA 18930-9637 |
Second Address | Ottsville, PA 18942-9669 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2006 |
Last Update Date | 19/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000089742 | HIGHMARK BLUE SHIELD ID (01) | PA |
0023261000 | BLUE CROSS HMO ID (01) | PA |