Healthcare Provider Details

I. General information

NPI: 1588060875
Provider Name (Legal Business Name): BLOOM REPRODUCTIVE INSTITUTE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8415 N PIMA RD STE 290
SCOTTSDALE AZ
85258-4480
US

IV. Provider business mailing address

8415 N PIMA RD STE 290
SCOTTSDALE AZ
85258-4480
US

V. Phone/Fax

Practice location:
  • Phone: 480-434-6565
  • Fax: 480-383-6426
Mailing address:
  • Phone: 480-434-6565
  • Fax: 480-383-6426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number42873
License Number StateAZ

VIII. Authorized Official

Name: MILLIE A BEHERA
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 480-434-6565