Provider Demographics
NPI:1164629218
Name:BLOOM, NATHAN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:MICHAEL
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66047-2090
Mailing Address - Country:US
Mailing Address - Phone:785-830-0100
Mailing Address - Fax:785-830-0115
Practice Address - Street 1:4921 W 18TH ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-2090
Practice Address - Country:US
Practice Address - Phone:785-830-0100
Practice Address - Fax:785-830-0115
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9406871207Q00000X
KS0432319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200672020AMedicaid
KS200672020AMedicaid