1992005326 NPI number — ALISA CAROLE BLOOM MPH, RDN, LDN

Table of content: ALISA CAROLE BLOOM MPH, RDN, LDN (NPI 1992005326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992005326 NPI number — ALISA CAROLE BLOOM MPH, RDN, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOOM
Provider First Name:
ALISA
Provider Middle Name:
CAROLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPH, RDN, LDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEVINE
Provider Other First Name:
ALISA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992005326
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1020 MILWAUKEE AVE
Provider Second Line Business Mailing Address:
SUITE 341
Provider Business Mailing Address City Name:
DEERFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60015-3513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-951-5557
Provider Business Mailing Address Fax Number:
847-941-0559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
SUITE 341
Provider Business Practice Location Address City Name:
DEERFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60015-3513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-951-5557
Provider Business Practice Location Address Fax Number:
847-941-0559
Provider Enumeration Date:
11/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  164-004502 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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