Provider Demographics
NPI:1740561679
Name:BLOOM, EDWARD J (DPT)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:6640 PARKDALE PL STE T
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5619
Practice Address - Country:US
Practice Address - Phone:317-808-7070
Practice Address - Fax:317-808-7073
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11414225100000X
IN05010015A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11414OtherPHYSICAL THERAPIST LICENSE