Provider Demographics
NPI:1093815565
Name:SCHLAKMAN, BRUCE N (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:N
Last Name:SCHLAKMAN
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 1:2500 N STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-2538
Mailing Address - Fax:601-815-1854
Practice Address - Street 1:2500 N STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-2538
Practice Address - Fax:601-815-1854
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME636312085N0700X, 2085R0202X
MS200322085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00604717OtherRAILROAD MEDICARE
MSP01198276OtherRAILROAD MEDICARE PTAN
AL157266Medicaid
FL375193701Medicaid
MS512G700003OtherMS MEDICARE - GROUP
DG7781OtherRAILROAD GRP#
FL375193701Medicaid
MS302I305450Medicare PIN
F65173Medicare UPIN
FL23207ZMedicare ID - Type Unspecified