Provider Demographics
NPI:1538405220
Name:JEFFREY BLOOM D.O. INC, DBA BACK BAY MEDICAL
Entity type:Organization
Organization Name:JEFFREY BLOOM D.O. INC, DBA BACK BAY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:949-263-1242
Mailing Address - Street 1:20311 SW ACACIA ST
Mailing Address - Street 2:#100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1733
Mailing Address - Country:US
Mailing Address - Phone:949-263-1242
Mailing Address - Fax:949-263-1280
Practice Address - Street 1:20311 SW ACACIA ST
Practice Address - Street 2:#100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1733
Practice Address - Country:US
Practice Address - Phone:949-263-1242
Practice Address - Fax:949-263-1280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6397207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty