Provider Demographics
NPI:1043579212
Name:R BRUCE PRINCE MD PC
Entity Type:Organization
Organization Name:R BRUCE PRINCE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:PRINCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-634-1195
Mailing Address - Street 1:1945 CLIFF VALLEY WAY NE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2477
Mailing Address - Country:US
Mailing Address - Phone:404-634-1195
Mailing Address - Fax:404-321-3987
Practice Address - Street 1:1945 CLIFF VALLEY WAY NE
Practice Address - Street 2:SUITE 260
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2477
Practice Address - Country:US
Practice Address - Phone:404-634-1195
Practice Address - Fax:404-321-3987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0123602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA012360170AMedicare PIN
GAD40905Medicare UPIN