Basic Information
| Provider Information | |||||||||
| NPI: | 1568643096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | HASBRO 122 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446484 | ||||||||
| FaxNumber: | 4014446378 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOPPIN ST | ||||||||
| Address2: | CORO WEST | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017938560 | ||||||||
| FaxNumber: | 4017938561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2007 | ||||||||
| LastUpdateDate: | 02/29/2008 | ||||||||
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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 | 2080P0216X | MD08885 | RI | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | MD08885 | 01 | RI | LICENSE | OTHER |