Basic Information
| Provider Information | |||||||||
| NPI: | 1548238835 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 COTTAGE GROVE RD | ||||||||
| Address2: | COTTAGE GROVE CARDIOLOGY | ||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602428756 | ||||||||
| FaxNumber: | 8602423052 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 COTTAGE GROVE RD | ||||||||
| Address2: | COTTAGE GROVE CARDIOLOGY | ||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602428756 | ||||||||
| FaxNumber: | 8602423052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 09/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 025827 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 001258276 | 05 | CT | MEDICAID | 060005792 | 01 | CT | RAILROAD MEDICARE | OTHER | 060000233 | 01 | CT | MEDICARE | OTHER |