Basic Information
| Provider Information | |||||||||
| NPI: | 1508877796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUCELLA | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 SAYBROOK RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606383820 | ||||||||
| FaxNumber: | 8606383824 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 SAYBROOK RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606383820 | ||||||||
| FaxNumber: | 8606383824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2251E1200X | 007755 | CT | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Ergonomics | 2251S0007X | 007755 | CT | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | 007755 | CT | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.