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General NPI Number Information
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NPI Number | 1457805244
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Entity Type | Organization
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Legal Business Name | BLOOM PLASTIC SURGERY SC
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Dates
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Enumeration Date | 08/09/2016
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Last Update Date | 08/09/2016
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Provider Practice Location Address
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Address Line | 150 E HURON ST SUITE 801
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City | CHICAGO
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State | IL
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Zip | 60611-2999
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Country | US
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Telephone | 312-549-8961
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Fax | 312-549-8962
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Provider Business Mailing Address
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Address Line | 150 E HURON ST SUITE 801
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City | CHICAGO
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State | IL
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Zip | 60611-2999
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Country | US
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Telephone | 312-549-8961
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Fax | 312-549-8962
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Authorized Official
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Title or Position | OWNER
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Name | JACOB BLOOM
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Credential | MD
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Telephone | 847-826-9239
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 336.095798
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License Number State | IL
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