Basic Information
| Provider Information | |||||||||
| NPI: | 1427152982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROECKER | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 BRANNAN RD | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302534310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782844040 | ||||||||
| FaxNumber: | 6782844076 | ||||||||
| Practice Location | |||||||||
| Address1: | 5445 MERIDIAN MARKS RD NE | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303424763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042525206 | ||||||||
| FaxNumber: | 4042521268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 01/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2088P0231X | 030437 | GA | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | Q30437 | 05 | SC | MEDICAID | AB9373387 | 01 | DEA | OTHER | 000362095C | 05 | GA | MEDICAID | 340019520 | 01 | GA | RAILROAD MEDICARE | OTHER |