Provider Demographics
NPI:1225001589
Name:BRUCE R MADDERN MD PA
Entity Type:Organization
Organization Name:BRUCE R MADDERN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MADDERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-398-5437
Mailing Address - Street 1:10475 CENTURION PKWY N
Mailing Address - Street 2:SUITE 302
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5003
Mailing Address - Country:US
Mailing Address - Phone:904-398-5437
Mailing Address - Fax:904-398-3077
Practice Address - Street 1:10475 CENTURION PKWY N
Practice Address - Street 2:SUITE 302
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5003
Practice Address - Country:US
Practice Address - Phone:904-398-5437
Practice Address - Fax:904-398-3077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Multi-Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8651OtherAV MED
45553OtherBC/BS OF FL