Provider Demographics
NPI:1104814201
Name:BLOOM, HEIDI TAYLOR (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:TAYLOR
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 E BARNETT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8674
Mailing Address - Country:US
Mailing Address - Phone:541-779-6250
Mailing Address - Fax:541-608-2535
Practice Address - Street 1:2780 E BARNETT RD STE 200
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8674
Practice Address - Country:US
Practice Address - Phone:541-779-6250
Practice Address - Fax:541-608-2535
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24000207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286646Medicaid
H71409Medicare UPIN
114026Medicare ID - Type Unspecified