Provider Demographics
NPI:1407904188
Name:BLOOM, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1007
Mailing Address - Country:US
Mailing Address - Phone:269-945-2192
Mailing Address - Fax:269-945-3937
Practice Address - Street 1:1510 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1007
Practice Address - Country:US
Practice Address - Phone:269-945-2192
Practice Address - Fax:269-945-3937
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4903603152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2813638Medicaid
MI6171910001Medicare NSC
MIU27870Medicare UPIN
MIN87460001Medicare PIN