Healthcare Provider Details

I. General information

NPI: 1861195463
Provider Name (Legal Business Name): HENRY BLOOMINGBURG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WEEMS ST
PURVIS MS
39475-4062
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-794-2224
  • Fax: 601-794-6392
Mailing address:
  • Phone: 601-264-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33688
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: