Basic Information
| Provider Information | |||||||||
| NPI: | 1790923969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITAKER | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1705 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309031705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068546008 | ||||||||
| FaxNumber: | 7067747230 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 WALTON WAY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067747745 | ||||||||
| FaxNumber: | 7067745789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2009 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 062124 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | 5101016483 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 5101016483 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1790923969 | 05 | MI | MEDICAID | 0E00425 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |