Healthcare Provider Details

I. General information

NPI: 1952481251
Provider Name (Legal Business Name): RICHARD R BLOOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 5TH AVE
COLUMBUS GA
31904
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 Number029589
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: