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NPI Code Detail

MEDICARE: ROBERT BLOOM PH.D.

MEDICARE: ROBERT BLOOM PH.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
1103TC0700XClinical PsychologistP0376TN
2103TC0700XClinical Psychologist04-4PAR

General Provider Information

NPI Number : 1730161910
Entity Type Code : Individual
Provider Name (Legal Business Name) : ROBERT BLOOM PH.D.
Provider Business Mailing Address
First Line : PO BOX 579
Second Line :
City : OLIVE BRANCH
State : MS
Zip : 38654-0579
Country : US
Telephone Number : 662-895-1707
Fax Number : 662-893-0388
Provider Business Practice Location Address
First Line : 5384 POPLAR AVE
Second Line : SUITE 313
City : MEMPHIS
State : TN
Zip : 38119-3609
Country : US
Telephone Number : 901-521-9671
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/15/2005
Last Update Date : 07/08/2007

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