Basic Information
Provider Information | |||||||||
NPI: | 1093764565 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLOOMER | ||||||||
FirstName: | COURTNAY | ||||||||
MiddleName: | WILLCOX | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2125 OAK GROVE RD STE 200 | ||||||||
Address2: |   | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945982520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9252967150 | ||||||||
FaxNumber: | 9252967171 | ||||||||
Practice Location | |||||||||
Address1: | 1331 NORTH ELM STREET | ||||||||
Address2: | SUITE 200 | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274016304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362749617 | ||||||||
FaxNumber: | 3364822177 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2006 | ||||||||
LastUpdateDate: | 10/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2014-01400 | NC | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 98050 | FL | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | 2014-01400 | NC | Y |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0700X | A103127 | CA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
No ID Information.