Healthcare Provider Details

I. General information

NPI: 1770757130
Provider Name (Legal Business Name): JACOB MAXWELL-PHILLIP BLOOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E DELAWARE PL STE 501
CHICAGO IL
60611-1666
US

IV. Provider business mailing address

1 E DELAWARE PL STE 501
CHICAGO IL
60611-1666
US

V. Phone/Fax

Practice location:
  • Phone: 312-549-8691
  • Fax: 312-549-8692
Mailing address:
  • Phone: 312-535-3721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number036134552
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036134552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: