1326290594 NPI number — DR BLOOMBERG EYE CLINIC

Table of content: (NPI 1326290594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326290594 NPI number — DR BLOOMBERG EYE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR BLOOMBERG EYE CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BLOOMBERG EYECARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326290594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1449 BOARDMAN CANFIELD RD
Provider Second Line Business Mailing Address:
STE 230
Provider Business Mailing Address City Name:
BOARDMAN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44512-8053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-758-6671
Provider Business Mailing Address Fax Number:
330-758-1451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1449 BOARDMAN CANFIELD RD
Provider Second Line Business Practice Location Address:
STE 230
Provider Business Practice Location Address City Name:
BOARDMAN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44512-8053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-758-6671
Provider Business Practice Location Address Fax Number:
330-758-1451
Provider Enumeration Date:
10/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BLOOMBERG
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
330-758-6671

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4008/T-032 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0754045 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 770910 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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