=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710986419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS CHARLES BLOOMQUIST CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2005
-----------------------------------------------------
Last Update Date | 06/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 MILES ST
-----------------------------------------------------
City | DAMARISCOTTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04543-4047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-563-4146
-----------------------------------------------------
Fax | 207-563-3717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 MILES ST
-----------------------------------------------------
City | DAMARISCOTTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04543-4047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-563-4146
-----------------------------------------------------
Fax | 207-563-3717
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 048605-23-11
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | RNA83341
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------