Healthcare Provider Details

I. General information

NPI: 1174850846
Provider Name (Legal Business Name): BLOOM FAMILY EYE SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 CHESTER BLVD
RICHMOND IN
47374-1221
US

IV. Provider business mailing address

1 CHILDRENS PLZ
DAYTON OH
45404-1898
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3020
  • Fax: 937-226-9605
Mailing address:
  • Phone: 937-641-3020
  • Fax: 937-226-9605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01051532A
License Number StateIN

VIII. Authorized Official

Name: DR. MICHAEL BLOOM
Title or Position: MD
Credential:
Phone: 937-641-3020