1073163580 NPI number — MICHAEL V BLOOM PHD LLC

Table of content: (NPI 1073163580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073163580 NPI number — MICHAEL V BLOOM PHD LLC

Organization/Personal Information

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

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:
1073163580
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2020
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:
09/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BLOOM
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
269-345-0669

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6301017079 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com