Provider Demographics
NPI:1437119997
Name:BRUIN, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:BRUIN
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 1:117 E KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5201
Mailing Address - Country:US
Mailing Address - Phone:314-251-6930
Mailing Address - Fax:
Practice Address - Street 1:516 S VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5019
Practice Address - Country:US
Practice Address - Phone:336-623-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102870207RX0202X, 2085R0001X
MO20200243552081H0002X
SC907602085R0001X
NC2021-020752085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102870Medicaid
IL036102870Medicaid
0970490001Medicare NSC
L78959Medicare PIN