Healthcare Provider Details

I. General information

NPI: 1609850932
Provider Name (Legal Business Name): ROBERT W BLOOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 08/28/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 W LAKE AVE SUITE LL19
GLENVIEW IL
60026-5812
US

IV. Provider business mailing address

3633 W LAKE AVE STE LL 19
GLENVIEW IL
60026-5812
US

V. Phone/Fax

Practice location:
  • Phone: 847-657-6007
  • Fax: 847-657-6412
Mailing address:
  • Phone: 847-657-6007
  • Fax: 847-657-6412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-069110
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: