Basic Information
| Provider Information | |||||||||
| NPI: | 1477530392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3272 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486053272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897971400 | ||||||||
| FaxNumber: | 9897974077 | ||||||||
| Practice Location | |||||||||
| Address1: | 7920 KIRKLAND CT | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490244974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693450669 | ||||||||
| FaxNumber: | 2693455354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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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 | 103T00000X | 109 | SD | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 6550540 | 05 | SD | MEDICAID |