=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497023741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R LAMONT BLOOM MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2011
-----------------------------------------------------
Last Update Date | 12/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 E CENTRAL AVE
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67202-1058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-265-0705
-----------------------------------------------------
Fax | 316-265-0785
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 E CENTRAL AVE
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67202-1058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-265-0705
-----------------------------------------------------
Fax | 316-265-0785
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. R. LAMONT BLOOM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 316-265-0705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 04-18702
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------