Basic Information
| Provider Information | |||||||||
| NPI: | 1073742664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOEMER | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19248 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175287541 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 206 N PEARL ST | ||||||||
| Address2: | |||||||||
| City: | TEUTOPOLIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624671134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178576481 | ||||||||
| FaxNumber: | 2178576094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2009 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036128692 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 561920 | 01 | IL | MEDICARE GROUP | OTHER | FB2120979 | 01 | IL | DEA | OTHER | 336090050 | 01 | IL | ILLINOIS CONTROLLED SUBSTANCE LICENSE | OTHER | 371391171004 | 05 | IL | MEDICAID | 036128692 | 01 | IL | ILLINOIS LICENSE | OTHER |