Provider Demographics
NPI:1164493896
Name:BRUDERLY, THOMAS E (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:BRUDERLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:20800 HARVARD RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HIGHLAND HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7251
Mailing Address - Country:US
Mailing Address - Phone:216-358-2315
Mailing Address - Fax:216-201-7237
Practice Address - Street 1:395 E MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1542
Practice Address - Country:US
Practice Address - Phone:330-762-8959
Practice Address - Fax:330-762-1224
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-6379207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0258500Medicaid
OHG29157Medicare UPIN
OHSP02511Medicare PIN
OH0258500Medicaid