Provider Demographics
NPI:1558505149
Name:JOHANNES V. BLOM, MD, PA
Entity Type:Organization
Organization Name:JOHANNES V. BLOM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNES
Authorized Official - Middle Name:V
Authorized Official - Last Name:BLOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-964-6114
Mailing Address - Street 1:3702 WASHINGTON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8282
Mailing Address - Country:US
Mailing Address - Phone:954-964-6114
Mailing Address - Fax:954-962-1994
Practice Address - Street 1:3702 WASHINGTON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8282
Practice Address - Country:US
Practice Address - Phone:954-964-6114
Practice Address - Fax:954-962-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94285174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1184654519OtherPROVIDER NPI
FL275038400Medicaid
FLU6937ZMedicare PIN