Healthcare Provider Details

I. General information

NPI: 1750577680
Provider Name (Legal Business Name): MICHAEL BLOOM MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8995 MAIN ST
CLARENCE NY
14031-1927
US

IV. Provider business mailing address

8995 MAIN ST
CLARENCE NY
14031-1927
US

V. Phone/Fax

Practice location:
  • Phone: 716-634-8989
  • Fax: 716-634-7544
Mailing address:
  • Phone: 716-634-8989
  • Fax: 716-634-7544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number142447-1
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL BLOOM
Title or Position: CEO
Credential: MD
Phone: 716-634-8989