MEDICARE: DR. GLENN 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	207P00000X	Emergency Medicine Physician	64512	GA

General Provider Information

NPI Number	:	1730374166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN R BLOOM MD

Provider Business Mailing Address
First Line	:	5665 NEW NORTHSIDE DR NW STE 320
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-5834
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5665 NEW NORTHSIDE DR NW STE 320
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-5834
Country	:	US
Telephone Number	:	770-874-5400
Fax Number	:

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

Provider Enumeration Date	:	09/10/2007
Last Update Date	:	08/12/2010

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

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