Healthcare Provider Details

I. General information

NPI: 1801074042
Provider Name (Legal Business Name): BYRON J BLOOM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

883 UNION ST
SHELBYVILLE TN
37160-2607
US

IV. Provider business mailing address

883 UNION ST
SHELBYVILLE TN
37160-2607
US

V. Phone/Fax

Practice location:
  • Phone: 931-685-1145
  • Fax: 931-685-8014
Mailing address:
  • Phone: 931-685-1145
  • Fax: 931-685-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number922
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: