Provider Demographics
NPI:1396879813
Name:ROSENBAUM-BLOOM, LAURA S (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:ROSENBAUM-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 1:4101 MAIN STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926
Mailing Address - Country:US
Mailing Address - Phone:843-342-6000
Mailing Address - Fax:843-342-6001
Practice Address - Street 1:4101 MAIN STREET
Practice Address - Street 2:SUITE C
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926
Practice Address - Country:US
Practice Address - Phone:843-342-6000
Practice Address - Fax:843-342-6001
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC223342084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC22334OtherMEDICAL LICENSE