Healthcare Provider Details

I. General information

NPI: 1124058342
Provider Name (Legal Business Name): MARK R BLADERGROEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 BREMO RD SUITE G-5
RICHMOND VA
23226-1934
US

IV. Provider business mailing address

5875 BREMO RD SUITE G-5
RICHMOND VA
23226-1934
US

V. Phone/Fax

Practice location:
  • Phone: 804-287-7840
  • Fax: 804-287-7845
Mailing address:
  • Phone: 804-287-7840
  • Fax: 804-287-7845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0101042193
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: