Healthcare Provider Details

I. General information

NPI: 1831273259
Provider Name (Legal Business Name): RICHARD R. BLOOM M.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 5TH AVE
COLUMBUS GA
31904-8916
US

IV. Provider business mailing address

PO BOX 7811
COLUMBUS GA
31908-7811
US

V. Phone/Fax

Practice location:
  • Phone: 706-576-4474
  • Fax: 706-576-5940
Mailing address:
  • Phone: 706-576-4474
  • Fax: 706-576-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD RICHARDO BLOOM
Title or Position: CEO
Credential: M.D.
Phone: 706-576-4474