Basic Information
| Provider Information | |||||||||
| NPI: | 1730151853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOMQUIST | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | VICTORIA | ||||||||
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| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CORPORATE WAY | ||||||||
| Address2: | MPG DOOR D | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330253925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542765681 | ||||||||
| FaxNumber: | 9549857074 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 N 35TH AVE | ||||||||
| Address2: | SUITE 205A | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542655846 | ||||||||
| FaxNumber: | 9549852451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 08/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | ME119246 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | HU529Z | 01 | FL | MEDICARE PTAN | OTHER | 011820100 | 05 | FL | MEDICAID |