Provider Demographics
NPI:1932410008
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:MRS
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 1:300 SE 17TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2550
Mailing Address - Country:US
Mailing Address - Phone:954-964-6114
Mailing Address - Fax:
Practice Address - Street 1:300 SE 17TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2550
Practice Address - Country:US
Practice Address - Phone:954-964-6114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94285207XS0114X, 207XX0005X, 207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275038400Medicaid
FL1184654519OtherPROVIDER NPI
FL275038400Medicaid