Provider Demographics
NPI:1235199696
Name:KINNEY, BRUCE LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEE
Last Name:KINNEY
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 1:2200 JEFFERSON AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512
Practice Address - Country:US
Practice Address - Phone:419-784-1414
Practice Address - Fax:419-783-2799
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009017807207V00000X
KY39346207V00000X
OH35-050789207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0658999Medicaid
KY64097256Medicaid
KY000000384921OtherANTHEM BLUE CROSS PIN
OHH327901OtherMEDICARE PTAN
KY0995701Medicare PIN
KY9957Medicare PIN
OHA16876Medicare UPIN
OH0658999Medicaid