Provider Demographics
NPI:1164581336
Name:BLOM, GARY P (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:P
Last Name:BLOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4550
Mailing Address - Country:US
Mailing Address - Phone:406-449-7458
Mailing Address - Fax:406-449-7496
Practice Address - Street 1:1732 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4550
Practice Address - Country:US
Practice Address - Phone:406-449-7458
Practice Address - Fax:406-449-7496
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT369111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000004513Medicare ID - Type UnspecifiedPROVIDER
MT000082546Medicare ID - Type UnspecifiedGROUP