Provider Demographics
NPI:1023401510
Name:ROBERT A BLOOM MD PLLC
Entity Type:Organization
Organization Name:ROBERT A BLOOM MD PLLC
Other - Org Name:ROBERT A BLOOM MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-338-4636
Mailing Address - Street 1:416 S. HENDERSON ST.
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-338-4636
Mailing Address - Fax:817-335-5421
Practice Address - Street 1:416 S. HENDERSON ST.
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-338-4636
Practice Address - Fax:817-335-5421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184011801Medicaid
TX396901Medicare UPIN