Healthcare Provider Details

I. General information

NPI: 1750919957
Provider Name (Legal Business Name): ANDREW JAMES BLOOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 ENGLE ST
ENGLEWOOD NJ
07631-2547
US

IV. Provider business mailing address

142 ENGLE ST
ENGLEWOOD NJ
07631-2547
US

V. Phone/Fax

Practice location:
  • Phone: 201-568-0033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number25MD00373000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: