Healthcare Provider Details

I. General information

NPI: 1043364680
Provider Name (Legal Business Name): BLOOM PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 E 14 MILE ROAD
BIRMINGHAM MI
48009
US

IV. Provider business mailing address

2055 E 14 MILE ROAD
BIRMINGHAM MI
48009
US

V. Phone/Fax

Practice location:
  • Phone: 248-645-1740
  • Fax: 248-645-5304
Mailing address:
  • Phone: 248-645-1740
  • Fax: 248-645-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberJE031896
License Number StateMI

VIII. Authorized Official

Name: KATHERINE SCHAFER
Title or Position: OWNER
Credential: D.O.
Phone: 248-835-5064