Basic Information
| Provider Information | |||||||||
| NPI: | 1922737923 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLOOM PEDIATRIC PARTNERS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 NORTH BROAD STREET EAST | ||||||||
| Address2: | |||||||||
| City: | ANGIER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275018954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063403138 | ||||||||
| FaxNumber: | 8774853477 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 NORTH BROAD STREET EAST | ||||||||
| Address2: | |||||||||
| City: | ANGIER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275018954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063403138 | ||||||||
| FaxNumber: | 8774853477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEAVERS | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7063403138 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD, PHD | ||||||||
| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.