1477530392 NPI number — MICHAEL V BLOOM PHD

Table of content: MICHAEL V BLOOM PHD (NPI 1477530392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477530392 NPI number — MICHAEL V BLOOM PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOOM
Provider First Name:
MICHAEL
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477530392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3272
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48605-3272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-797-1400
Provider Business Mailing Address Fax Number:
989-797-4077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7920 KIRKLAND CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-4974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-345-0669
Provider Business Practice Location Address Fax Number:
269-345-5354
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  109 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6550540 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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