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General NPI Number Information
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NPI Number | 1275805848
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Entity Type | Individual
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Provider Name | LAWRENCE MICHAEL BLOOM M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/30/2012
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Last Update Date | 01/30/2012
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Provider Practice Location Address
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Address Line | 31 WASHINGTION SQUARE WEST
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City | NEW YORK
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State | NY
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Zip | 10011-0000
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Country | US
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Telephone | 973-746-0447
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Fax |
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Provider Business Mailing Address
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Address Line | 517 PARK ST
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City | UPPER MONTCLAIR
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State | NJ
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Zip | 07043-1963
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Country | US
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Telephone | 973-746-0447
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | 0967331
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License Number State | NY
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