Provider Demographics
NPI:1033370762
Name:BENNETT H. BRUCKNER,M.D., P.C.
Entity Type:Organization
Organization Name:BENNETT H. BRUCKNER,M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BRUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-962-9410
Mailing Address - Street 1:575 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3333
Mailing Address - Country:US
Mailing Address - Phone:770-962-9410
Mailing Address - Fax:770-962-8489
Practice Address - Street 1:575 PROFESSIONAL DR
Practice Address - Street 2:SUITE 290
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3333
Practice Address - Country:US
Practice Address - Phone:770-962-9410
Practice Address - Fax:770-962-8489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034547207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1639270622OtherNPI
GA00473228AMedicaid
GAA98095Medicare UPIN