Provider Demographics
NPI:1831273259
Name:RICHARD R. BLOOM M.D. LLC
Entity type:Organization
Organization Name:RICHARD R. BLOOM M.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:RICHARDO
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-576-4474
Mailing Address - Street 1:PO BOX 7811
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-7811
Mailing Address - Country:US
Mailing Address - Phone:706-576-4474
Mailing Address - Fax:706-576-5940
Practice Address - Street 1:1900 5TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8916
Practice Address - Country:US
Practice Address - Phone:706-576-4474
Practice Address - Fax:706-576-5940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA312282Medicaid
GA00476693Medicaid
GAE61541Medicare UPIN
GA00476693Medicaid