Healthcare Provider Details

I. General information

NPI: 1265437057
Provider Name (Legal Business Name): BRADFORD J BOMBA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S LANDMARK AVE
BLOOMINGTON IN
47403-3239
US

IV. Provider business mailing address

550 S LANDMARK AVE
BLOOMINGTON IN
47403-3239
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-3409
  • Fax: 812-331-3656
Mailing address:
  • Phone: 812-331-3409
  • Fax: 812-331-3656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number10137706A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01037706A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: