Healthcare Provider Details

I. General information

NPI: 1184601908
Provider Name (Legal Business Name): PAUL HENRY BLOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3448 US ROUTE 60
HUNTINGTON WV
25705-2906
US

IV. Provider business mailing address

PO BOX 910 RADIOLOGY INC
HUNTINGTON WV
25712-0910
US

V. Phone/Fax

Practice location:
  • Phone: 304-522-1550
  • Fax: 304-522-0704
Mailing address:
  • Phone: 304-522-1550
  • Fax: 304-522-1073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35-085169
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number39150
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number21514
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: