Provider Demographics
NPI:1750577680
Name:MICHAEL BLOOM MD
Entity type:Organization
Organization Name:MICHAEL BLOOM MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-634-8989
Mailing Address - Street 1:8995 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:NY
Mailing Address - Zip Code:14031-1927
Mailing Address - Country:US
Mailing Address - Phone:716-634-8989
Mailing Address - Fax:716-634-7544
Practice Address - Street 1:8995 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-1927
Practice Address - Country:US
Practice Address - Phone:716-634-8989
Practice Address - Fax:716-634-7544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142447-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB35571Medicare UPIN
NY001091Medicare PIN