Provider Demographics
NPI:1144285560
Name:BLOOMSTINE, MARK T (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:BLOOMSTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2315 MYRTLE ST STE L10
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4611
Mailing Address - Country:US
Mailing Address - Phone:814-454-2401
Mailing Address - Fax:814-459-5992
Practice Address - Street 1:2315 MYRTLE ST STE L10
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4611
Practice Address - Country:US
Practice Address - Phone:814-454-2401
Practice Address - Fax:814-459-5992
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044032L207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000665455OtherHIGHMARK
PA0012416530002Medicaid
200019047OtherRAILROAD MEDICARE
PA0467410001Medicare NSC
PA665455D3RMedicare PIN
E81207Medicare UPIN