Healthcare Provider Details

I. General information

NPI: 1861396095
Provider Name (Legal Business Name): RYAN BLOOM DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WEBER RD
O FALLON IL
62269-2248
US

IV. Provider business mailing address

1422 ASHFIELD GLN
O FALLON IL
62269-6799
US

V. Phone/Fax

Practice location:
  • Phone: 618-795-0804
  • Fax:
Mailing address:
  • Phone: 618-795-0804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.041029
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: