Provider Demographics
NPI:1316923253
Name:BLOOM, PETER D (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MAPLE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2917
Mailing Address - Country:US
Mailing Address - Phone:716-626-5250
Mailing Address - Fax:716-332-2218
Practice Address - Street 1:60 MAPLE RD
Practice Address - Street 2:STE 1
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2917
Practice Address - Country:US
Practice Address - Phone:716-626-5250
Practice Address - Fax:716-332-2218
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2375901207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7130845OtherAETNA
104399OtherGHI
NY175336BTOtherPREFERRED CARE
NY2313009OtherINDEPENDENT HEALTH
NY000528291001OtherBLUE CROSS OF WNY
NY00027351201OtherUNIVERA
NY02697414Medicaid
105127OtherGHI HMO
NY175336BTOtherPREFERRED CARE
NYRA8494Medicare ID - Type Unspecified