Provider Demographics
NPI:1295961357
Name:VICTOR BLOOM, M.D., P.C.
Entity type:Organization
Organization Name:VICTOR BLOOM, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-882-8640
Mailing Address - Street 1:1007 THREE MILE DR
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1412
Mailing Address - Country:US
Mailing Address - Phone:313-882-8640
Mailing Address - Fax:313-882-8641
Practice Address - Street 1:1007 THREE MILE DR
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-1412
Practice Address - Country:US
Practice Address - Phone:313-882-8640
Practice Address - Fax:313-882-8641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI022723102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty