Healthcare Provider Details

I. General information

NPI: 1760414940
Provider Name (Legal Business Name): DAVID J BLOOM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-5555
  • Fax: 570-271-6578
Mailing address:
  • Phone: 570-271-5555
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA001742L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: