Provider Demographics
NPI:1417077272
Name:BLOOM, RICHARD B (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:95068 SPRING TIDE LN
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-5460
Mailing Address - Country:US
Mailing Address - Phone:904-277-2803
Mailing Address - Fax:904-277-2803
Practice Address - Street 1:3730 N RIDGE RD STE 200
Practice Address - Street 2:KANSAS ENDOVASCULAR MEDICINE ASSOCIATES
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1228
Practice Address - Country:US
Practice Address - Phone:316-462-1070
Practice Address - Fax:316-462-1078
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST01157207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD60688Medicare UPIN