Provider Demographics
NPI:1528246683
Name:BLOOMINGTON MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:BLOOMINGTON MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-263-8763
Mailing Address - Street 1:1761 BEALL AVE
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2342
Mailing Address - Country:US
Mailing Address - Phone:330-263-8428
Mailing Address - Fax:330-263-8190
Practice Address - Street 1:1761 BEALL AVE
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2342
Practice Address - Country:US
Practice Address - Phone:330-263-8428
Practice Address - Fax:330-263-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2836560Medicaid
OHBL9374561Medicare PIN