Provider Demographics
NPI:1043393671
Name:BRUINS, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BRUINS
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 1:4747 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-3539
Mailing Address - Country:US
Mailing Address - Phone:317-283-5753
Mailing Address - Fax:
Practice Address - Street 1:4747 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-3539
Practice Address - Country:US
Practice Address - Phone:317-283-5753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027233207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN225210ROtherMEDICARE GROUP MEMBER PIN/PTAN
IN100059200Medicaid
797600Medicare PIN
IN225210ROtherMEDICARE GROUP MEMBER PIN/PTAN