Healthcare Provider Details

I. General information

NPI: 1851409387
Provider Name (Legal Business Name): ALLEN DAVID BLOOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 OGDEN AVE SUITE 115
AURORA IL
60504-7206
US

IV. Provider business mailing address

2040 OGDEN AVE STE 115
AURORA IL
60504-7205
US

V. Phone/Fax

Practice location:
  • Phone: 630-585-0200
  • Fax: 630-585-7396
Mailing address:
  • Phone: 630-585-0200
  • Fax: 630-585-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036067856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: