Provider Demographics
NPI:1336317551
Name:BRUCE W KRELL DPM PC
Entity Type:Organization
Organization Name:BRUCE W KRELL DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:KRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:480-807-8532
Mailing Address - Street 1:2905 W WARNER RD
Mailing Address - Street 2:STE 26
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-1674
Mailing Address - Country:US
Mailing Address - Phone:480-807-8532
Mailing Address - Fax:480-807-0420
Practice Address - Street 1:2905 W WARNER RD
Practice Address - Street 2:STE 26
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-1674
Practice Address - Country:US
Practice Address - Phone:480-807-8532
Practice Address - Fax:480-807-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ00316213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ00014417OtherBANNER HEALTH INSURANCE
AZAZ00316OtherSTATE LICENSE
AZ069965Medicaid
AZAZ0191480OtherBCBS AZ
AZ0712920001Medicare NSC
AZAZ00316OtherSTATE LICENSE
AZU16791Medicare PIN