Organization
DERMATOLOGY CENTER FOR CHILDREN & YOUNG ADULTS PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KENNETH E BLOOM MD (PRESIDENT)
(651) 379-9999
Entity
Organization
Contact information
Practice address
2795 PILOT KNOB RD, SUITE 300, EAGAN, MN 55121-1176
(651) 379-9999
(651) 379-9900
Mailing address
2795 PILOT KNOB RD, SUITE 300, EAGAN, MN 55121-1176
(651) 379-9999
(651) 379-9900
Taxonomy
Speciality
Code
Description
License number
State
207NP0225X
Pediatric Dermatology Physician
Primary
—
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
013837
—
ND
01
—
2M741DE
BLUE CROSS BLUE SHIELD
—
Enumeration date
09/16/2006
Last updated
04/20/2008
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