Basic Information
| Provider Information | |||||||||
| NPI: | 1700336781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUCH | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11528 US HIGHWAY 19 | ||||||||
| Address2: | |||||||||
| City: | PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346681442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278682151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11528 US HIGHWAY 19 | ||||||||
| Address2: | |||||||||
| City: | PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346681442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278682151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2016 | ||||||||
| LastUpdateDate: | 03/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.020108 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 4704325400 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN9488436 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1700336781 | 05 | MI | MEDICAID | PENDING | 05 | OH | MEDICAID |