Healthcare Provider Details

I. General information

NPI: 1942136650
Provider Name (Legal Business Name): BLOOM360 MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21509 GARRISON ST
DEARBORN MI
48124-2301
US

IV. Provider business mailing address

21509 GARRISON ST
DEARBORN MI
48124-2301
US

V. Phone/Fax

Practice location:
  • Phone: 313-205-8939
  • Fax:
Mailing address:
  • Phone: 313-205-8939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NADINE KAMEL JAWAD
Title or Position: CMO
Credential: MD
Phone: 313-205-8939