Basic Information
| Provider Information | |||||||||
| NPI: | 1578658720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICICCO-BLOOM | ||||||||
| FirstName: | EMANUEL | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 WEST GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | RED BANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120051 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 FRENCH ST STE 2300 | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322357875 | ||||||||
| FaxNumber: | 7322356620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | MA54781 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2080P0008X | 25MA05478100 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 0870706 | 05 | NJ | MEDICAID |