| Entity Name: | JESSICA BLOOMGARDEN MD PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 21 Nov 2017 (7 years ago) |
| Document Number: | P17000093325 |
| FEI/EIN Number | 82-3504459 |
| Address: | 109 MONTCLAIRE DRIVE, WESTON, FL, 33326 |
| Mail Address: | 109 MONTCLAIRE DRIVE, WESTON, FL, 33326 |
| ZIP code: | 33326 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1558877068 | 2017-12-19 | 2017-12-19 | 109 MONTCLAIRE DR, WESTON, FL, 333263587, US | 4399 N NOB HILL RD, SUNRISE, FL, 333515813, US | |||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||
| Phone | +1 646-265-9264 |
| Phone | +1 954-746-1505 |
Authorized person
| Name | DR. JESSICA BLOOMGARDEN |
| Role | PRESIDENT |
| Phone | 6462659264 |
Taxonomy
| Taxonomy Code | 261QM2500X - Medical Specialty Clinic/Center |
| License Number | ME116270 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1013158427 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BLOOMGARDEN JESSICA | Agent | 109 MONTCLAIRE DRIVE, WESTON, FL, 33326 |
| Name | Role | Address |
|---|---|---|
| BLOOMGARDEN JESSICA | President | 109 MONTCLAIRE DRIVE, WESTON, FL, 33326 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-04 |
| ANNUAL REPORT | 2023-01-26 |
| ANNUAL REPORT | 2022-02-03 |
| ANNUAL REPORT | 2021-01-28 |
| ANNUAL REPORT | 2020-02-12 |
| ANNUAL REPORT | 2019-03-21 |
| ANNUAL REPORT | 2018-07-02 |
| Domestic Profit | 2017-11-21 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
