Healthcare Provider Details

I. General information

NPI: 1497023741
Provider Name (Legal Business Name): R LAMONT BLOOM MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 E CENTRAL AVE
WICHITA KS
67202-1058
US

IV. Provider business mailing address

406 E CENTRAL AVE
WICHITA KS
67202-1058
US

V. Phone/Fax

Practice location:
  • Phone: 316-265-0705
  • Fax: 316-265-0785
Mailing address:
  • Phone: 316-265-0705
  • Fax: 316-265-0785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number04-18702
License Number StateKS

VIII. Authorized Official

Name: DR. R. LAMONT BLOOM
Title or Position: PRESIDENT
Credential: MD
Phone: 316-265-0705