Basic Information
| Provider Information | |||||||||
| NPI: | 1326098849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCHEY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAYS | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHYSICIAN ASSISTANT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1838 GREENE TREE RD | ||||||||
| Address2: | SUITE 150 LL | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212086391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106029262 | ||||||||
| FaxNumber: | 4106029276 | ||||||||
| Practice Location | |||||||||
| Address1: | 9105 FRANKLIN SQUARE DR | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212373930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106029262 | ||||||||
| FaxNumber: | 4106029276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 4756 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | C0004030 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 168403YUT | 01 | MD | MEDICARE | OTHER |