Provider Demographics
NPI:1457584468
Name:JOHANNES V. BLOM, MD, PA
Entity type:Organization
Organization Name:JOHANNES V. BLOM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-964-6114
Mailing Address - Street 1:3702 WASHINGTON ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8282
Mailing Address - Country:US
Mailing Address - Phone:954-964-6114
Mailing Address - Fax:954-962-1994
Practice Address - Street 1:601 N FLAMINGO RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1015
Practice Address - Country:US
Practice Address - Phone:954-964-6114
Practice Address - Fax:954-962-1994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94285207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty