Healthcare Provider Details

I. General information

NPI: 1114769411
Provider Name (Legal Business Name): DUSTIN BLOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 06/10/2024
Certification Date: 06/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HURLEY PLZ
FLINT MI
48503-5902
US

IV. Provider business mailing address

5344 NORTHWAY DR
SWARTZ CREEK MI
48473-8227
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-9200
  • Fax:
Mailing address:
  • Phone: 810-835-1056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number4704370340
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: