MEDICARE: DR. HENRY R BLOOM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35-039371	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003893025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRY R BLOOM MD

Provider Business Mailing Address
First Line	:	20620 JOHN CARROLL BLVD
Second Line	:	SUITE 208
City	:	UNIVERSITY HEIGHTS
State	:	OH
Zip	:	44118-4540
Country	:	US
Telephone Number	:	216-321-9703
Fax Number	:	216-321-9704

Provider Business Practice Location Address
First Line	:	20620 JOHN CARROLL BLVD
Second Line	:	SUITE 208
City	:	UNIVERSITY HEIGHTS
State	:	OH
Zip	:	44118-4540
Country	:	US
Telephone Number	:	216-321-9703
Fax Number	:	216-321-9704

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	07/16/2012

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Directions to “ DR. HENRY R BLOOM MD” Practice Location

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