Provider Demographics
NPI:1184601908
Name:BLOM, PAUL HENRY (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:HENRY
Last Name:BLOM
Suffix:
Gender:M
Credentials:MD
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 910
Mailing Address - Street 2:RADIOLOGY INC
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25712-0910
Mailing Address - Country:US
Mailing Address - Phone:304-522-1550
Mailing Address - Fax:304-522-1073
Practice Address - Street 1:3448 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2906
Practice Address - Country:US
Practice Address - Phone:304-522-1550
Practice Address - Fax:304-522-0704
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0851692085R0202X
KY391502085R0202X
WV215142085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000011745OtherMTN STATE BCBS
WV1810941000Medicaid
WVP00099468OtherRR MEDICARE (WV)
WV55079337600OtherWORKMANS COMP
OH000000205297OtherUNISON
KY6407884300Medicaid
KY50007259OtherPASSPORT
OH2466031Medicaid
7061267OtherAETNA
7061267OtherAETNA
OH000000205297OtherUNISON
KY6407884300Medicaid
WV4129241Medicare PIN