Provider Demographics
NPI:1912747106
Name:BLOOM PHYSICIAN HOUSECALLS, PA
Entity type:Organization
Organization Name:BLOOM PHYSICIAN HOUSECALLS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MOON WADELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-923-1250
Mailing Address - Street 1:12600 W COLFAX AVE STE B200
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-3736
Mailing Address - Country:US
Mailing Address - Phone:720-923-1250
Mailing Address - Fax:
Practice Address - Street 1:8000 W IH 10 STE 240
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-3868
Practice Address - Country:US
Practice Address - Phone:720-923-1250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-28
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty