Basic Information
| Provider Information | |||||||||
| NPI: | 1831184704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | WILLIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414200 | ||||||||
| FaxNumber: | 2704414249 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414200 | ||||||||
| FaxNumber: | 2704414249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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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 | 208000000X | 20596 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64205966 | 05 | KY | MEDICAID |