Basic Information
| Provider Information | |||||||||
| NPI: | 1548202526 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2716 MONA LISA ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890440318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028379195 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 W CHARLESTON BLVD | ||||||||
| Address2: | UNIVERSITY MEDICAL CENTER | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023831958 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 02/20/2009 | ||||||||
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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 | 207P00000X | 510104304 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 1111 | NV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 114835231 | 05 | MI | MEDICAID | CB014304 | 01 | MI | BC/BS | OTHER |