Provider Demographics
NPI:1144530155
Name:JEANNIE BLOM MD PC
Entity type:Organization
Organization Name:JEANNIE BLOM MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-849-3443
Mailing Address - Street 1:PO BOX 190218
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31119-0218
Mailing Address - Country:US
Mailing Address - Phone:866-214-8600
Mailing Address - Fax:678-888-0390
Practice Address - Street 1:2722 N. DECATUR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:404-849-3443
Practice Address - Fax:404-467-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041517208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty