MEDICARE: RICHARD B BLOOM DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	T01157	KS

General Provider Information

NPI Number	:	1417077272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD B BLOOM DO

Provider Business Mailing Address
First Line	:	95068 SPRING TIDE LN
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-5460
Country	:	US
Telephone Number	:	904-277-2803
Fax Number	:	904-277-2803

Provider Business Practice Location Address
First Line	:	3730 N RIDGE RD STE 200
Second Line	:	KANSAS ENDOVASCULAR MEDICINE ASSOCIATES
City	:	WICHITA
State	:	KS
Zip	:	67205-1228
Country	:	US
Telephone Number	:	316-462-1070
Fax Number	:	316-462-1078

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/08/2007

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