Provider Demographics
NPI:1114769411
Name:BLOM, DUSTIN
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:BLOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5344 NORTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-8227
Mailing Address - Country:US
Mailing Address - Phone:810-835-1056
Mailing Address - Fax:
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704370340163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine