MEDICARE: DR. ELLIE BLOOMFIELD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	G65919	CA

General Provider Information

NPI Number	:	1013977206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLIE BLOOMFIELD M.D.

Provider Business Mailing Address
First Line	:	1808 VERDUGO BLVD
Second Line	:	SUITE 403
City	:	GLENDALE
State	:	CA
Zip	:	91208-1477
Country	:	US
Telephone Number	:	818-790-7098
Fax Number	:	818-790-7099

Provider Business Practice Location Address
First Line	:	1808 VERDUGO BLVD
Second Line	:	SUITE 403
City	:	GLENDALE
State	:	CA
Zip	:	91208-1477
Country	:	US
Telephone Number	:	818-790-7098
Fax Number	:	818-790-7099

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	08/24/2010

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