Healthcare Provider Details

I. General information

NPI: 1194394502
Provider Name (Legal Business Name): SAMUEL BLOOMSBURG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 1ST ST
MORRIS MN
56267-1408
US

IV. Provider business mailing address

400 E 1ST ST
MORRIS MN
56267-1408
US

V. Phone/Fax

Practice location:
  • Phone: 320-589-1313
  • Fax: 320-589-1065
Mailing address:
  • Phone: 320-589-1313
  • Fax: 320-589-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberRL17467
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: