Healthcare Provider Details

I. General information

NPI: 1114905411
Provider Name (Legal Business Name): ARIC NEIL BLOM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2361 PAYSPHERE CIR
CHICAGO IL
60674
US

IV. Provider business mailing address

2520 ELISHA AVE
ZION IL
60099
US

V. Phone/Fax

Practice location:
  • Phone: 847-746-4358
  • Fax:
Mailing address:
  • Phone: 847-872-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number010497
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2095
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.003370
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: