MEDICARE: MR. MICHAEL SCOTT BLOOM M.D.

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	207W00000X	Ophthalmology Physician	207W00000X	OH
2	207WX0110X	Pediatric Ophthalmology and Strabismus Specialist Physician	35066075B	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	:	1639128689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL SCOTT BLOOM M.D.

Provider Business Mailing Address
First Line	:	1020 WOODMAN DR STE 105
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45432-1446
Country	:	US
Telephone Number	:	937-723-7772
Fax Number	:	937-226-9605

Provider Business Practice Location Address
First Line	:	1020 WOODMAN DR STE 105
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45432-1446
Country	:	US
Telephone Number	:	937-723-7772
Fax Number	:	937-226-9605

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	10/28/2021

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