Provider Demographics
NPI:1457805244
Name:BLOOM PLASTIC SURGERY SC
Entity Type:Organization
Organization Name:BLOOM PLASTIC SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-826-9239
Mailing Address - Street 1:150 E HURON ST
Mailing Address - Street 2:SUITE 801
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2999
Mailing Address - Country:US
Mailing Address - Phone:312-549-8961
Mailing Address - Fax:312-549-8962
Practice Address - Street 1:150 E HURON ST
Practice Address - Street 2:SUITE 801
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2999
Practice Address - Country:US
Practice Address - Phone:312-549-8961
Practice Address - Fax:312-549-8962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.095798174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty