Basic Information
| Provider Information | |||||||||
| NPI: | 1609967132 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DR | ||||||||
| Address2: | 4TH FLOOR CLINIC B ROOM 4807 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481094217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349367030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 04/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 4301047893 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 208800000X | 4301047893 | MI | Y | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | 4301047893 | MI | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 1594500 | 05 | MI | MEDICAID |