Provider Demographics
NPI:1477530392
Name:BLOOM, MICHAEL V (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:V
Last Name:BLOOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3272
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48605-3272
Mailing Address - Country:US
Mailing Address - Phone:989-797-1400
Mailing Address - Fax:989-797-4077
Practice Address - Street 1:7920 KIRKLAND CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4974
Practice Address - Country:US
Practice Address - Phone:269-345-0669
Practice Address - Fax:269-345-5354
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD109103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6550540Medicaid
SDS1526Medicare PIN