Healthcare Provider Details

I. General information

NPI: 1790851996
Provider Name (Legal Business Name): ILENE S BLOOM PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 DEFENSE HWY SUITE 400
ANNAPOLIS MD
21401-7027
US

IV. Provider business mailing address

116 DEFENSE HWY SUITE 400
ANNAPOLIS MD
21401-7027
US

V. Phone/Fax

Practice location:
  • Phone: 410-897-9841
  • Fax: 410-897-9852
Mailing address:
  • Phone: 410-897-9841
  • Fax: 410-897-9852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC01316
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: