Provider Demographics
NPI:1770577330
Name:BLOOMBERG, RICHARD D (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:BLOOMBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 ORCHARD PARK RD
Mailing Address - Street 2:A103
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2646
Mailing Address - Country:US
Mailing Address - Phone:716-677-5500
Mailing Address - Fax:716-677-5008
Practice Address - Street 1:550 ORCHARD PARK RD
Practice Address - Street 2:A103
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2646
Practice Address - Country:US
Practice Address - Phone:716-677-5500
Practice Address - Fax:716-677-5008
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241414208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115139OtherINDEPENDENT HEALTH
0192612OtherGHI PPO
NY02591862Medicaid
241414-2WOtherWORKERS COMPENSATION
000415467003OtherBC/BS
NYP00475424OtherRRM
00028422901OtherUNIVERA
NYI20862Medicare UPIN
000415467003OtherBC/BS