Healthcare Provider Details

I. General information

NPI: 1417077272
Provider Name (Legal Business Name): RICHARD B BLOOM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3730 N RIDGE RD STE 200 KANSAS ENDOVASCULAR MEDICINE ASSOCIATES
WICHITA KS
67205-1228
US

IV. Provider business mailing address

95068 SPRING TIDE LN
FERNANDINA BEACH FL
32034-5460
US

V. Phone/Fax

Practice location:
  • Phone: 316-462-1070
  • Fax: 316-462-1078
Mailing address:
  • Phone: 904-277-2803
  • Fax: 904-277-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberT01157
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: