1245234749 NPI number — GREGORY J BRUCHS O.D.

Table of content: GREGORY J BRUCHS O.D. (NPI 1245234749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245234749 NPI number — GREGORY J BRUCHS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUCHS
Provider First Name:
GREGORY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1245234749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 GOVERNORS PLACE BLVD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
KETTERING
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45409-1335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-297-7676
Provider Business Mailing Address Fax Number:
937-297-7690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 GOVERNORS PLACE BLVD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
KETTERING
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45409-1335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-297-7676
Provider Business Practice Location Address Fax Number:
937-297-7690
Provider Enumeration Date:
06/13/2005

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: 152W00000X , with the licence number:  3399 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0449009 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0510790001 . This is a "DMERC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2280338 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000009496 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 310949280026 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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