Basic Information
| Provider Information | |||||||||
| NPI: | 1144530155 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEANNIE BLOM MD PC | ||||||||
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| OtherOrganizationName: | JEANNIE-IN-A-BOTTLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190218 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311190218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662148600 | ||||||||
| FaxNumber: | 6788880390 | ||||||||
| Practice Location | |||||||||
| Address1: | 2722 N. DECATUR | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048493443 | ||||||||
| FaxNumber: | 4044671004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2010 | ||||||||
| LastUpdateDate: | 12/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | BLOM | ||||||||
| AuthorizedOfficialFirstName: | JEANNIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4048493443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 041517 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.