Provider Demographics
NPI:1003815366
Name:THAYER, BRUCE ALDEN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALDEN
Last Name:THAYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 WASHINGTON ST
Mailing Address - Street 2:SUITE 665
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1650
Mailing Address - Country:US
Mailing Address - Phone:617-243-3724
Mailing Address - Fax:617-243-9993
Practice Address - Street 1:2000 WASHINGTON ST
Practice Address - Street 2:SUITE 665
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1650
Practice Address - Country:US
Practice Address - Phone:617-243-3724
Practice Address - Fax:617-243-9993
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30063208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2019159Medicaid
B75685Medicare UPIN
MAM07886Medicare ID - Type Unspecified