MEDICARE: DR. MYRON E 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	16361	WA

General Provider Information

NPI Number	:	1588727234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYRON E BLOOM MD

Provider Business Mailing Address
First Line	:	3804 S DEARBORN ST
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99223-1239
Country	:	US
Telephone Number	:	509-939-4042
Fax Number	:

Provider Business Practice Location Address
First Line	:	3804 S DEARBORN ST
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99223-1239
Country	:	US
Telephone Number	:	509-939-4042
Fax Number	:

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

Provider Enumeration Date	:	12/17/2006
Last Update Date	:	07/08/2007

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