Basic Information
| Provider Information | |||||||||
| NPI: | 1427092212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURELL | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 HADLEY RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461581934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178319340 | ||||||||
| FaxNumber: | 3178345768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01035248 | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 208VP0000X | 01035248A | IN | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207Q00000X | 01035248A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200103280 | 05 | IN | MEDICAID |