=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831169705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTSIDE BONE & JOINT CLINIC,PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2006
-----------------------------------------------------
Last Update Date | 11/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 FROSTWOOD DR SUITE 314
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-932-7400
-----------------------------------------------------
Fax | 713-932-8224
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 902 FROSTWOOD DR SUITE 314
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77024-2420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-932-7400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARTIN L BLOOM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 713-932-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | F8414
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------