Provider Demographics
NPI:1124058342
Name:BLADERGROEN, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:BLADERGROEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5875 BREMO RD
Mailing Address - Street 2:SUITE G-5
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1934
Mailing Address - Country:US
Mailing Address - Phone:804-287-7840
Mailing Address - Fax:804-287-7845
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:SUITE G-5
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-287-7840
Practice Address - Fax:804-287-7845
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101042193208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN
VA7300221Medicaid
VA0101042193OtherMEDICAL LICENSE
VA0101042193OtherMEDICAL LICENSE
VA0101042193OtherMEDICAL LICENSE