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General NPI Number Information
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NPI Number | 1104822881
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Entity Type | Individual
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Provider Name | FRED A. BLOOM M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/27/2005
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 67 SILVER STREET
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City | WATERVILLE
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State | ME
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Zip | 04901
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Country | US
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Telephone | 207-873-1636
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Fax |
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Provider Business Mailing Address
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Address Line | 67 JOURNEY'S END RD.
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City | MT. VERNON
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State | ME
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Zip | 04352
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Country | US
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Telephone | 207-873-1636
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 007673
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License Number State | ME
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