MEDICARE: MS. KELSEY RAE GEORGE BLOOM PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	13535-24	WI
2	225100000X	Physical Therapist	070.022615	IL

General Provider Information

NPI Number	:	1184171696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELSEY RAE GEORGE BLOOM PT, DPT

Provider Business Mailing Address
First Line	:	7349 S 69TH ST
Second Line	:
City	:	FRANKLIN
State	:	WI
Zip	:	53132-9208
Country	:	US
Telephone Number	:	608-219-3676
Fax Number	:

Provider Business Practice Location Address
First Line	:	1585 N MILWAUKEE AVE STE 101
Second Line	:
City	:	LIBERTYVILLE
State	:	IL
Zip	:	60048-1359
Country	:	US
Telephone Number	:	847-918-7947
Fax Number	:	847-918-9622

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	05/17/2022

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