1003876533 NPI number — DR. BRUCE J TRUSOCK MD

Table of content: DR. BRUCE J TRUSOCK MD (NPI 1003876533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003876533 NPI number — DR. BRUCE J TRUSOCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRUSOCK
Provider First Name:
BRUCE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003876533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 EXPLORER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GWINN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49841-2813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-346-4924
Provider Business Mailing Address Fax Number:
906-346-6474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MACINNES DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUGHTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49930-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-483-1860
Provider Business Practice Location Address Fax Number:
906-483-1166
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 204C00000X , with the licence number:  43040911 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: BT040911 . This is a "BLUECROSS STATE ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0C16002 . This is a "MEDICARE GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0829560001 . This is a "MEDICARE DME" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 103231075 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com