Healthcare Provider Details

I. General information

NPI: 1811983372
Provider Name (Legal Business Name): KENNETH EVAN BLOOM DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 PROFESSIONAL PARK DR SUITE C
MOORESVILLE NC
28117-6540
US

IV. Provider business mailing address

137 PROFESSIONAL PARK DR SUITE C
MOORESVILLE NC
28117-6540
US

V. Phone/Fax

Practice location:
  • Phone: 704-662-8336
  • Fax: 704-662-8525
Mailing address:
  • Phone: 704-662-8336
  • Fax: 704-662-8525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number414
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number414
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: