Healthcare Provider Details

I. General information

NPI: 1235196486
Provider Name (Legal Business Name): ROGER EARL BLOOMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 SPRINGPORT RD STE 500
JACKSON MI
49202
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-3273
  • Fax: 517-205-1698
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number4301075147
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301075147
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: