Provider Demographics
NPI:1437568482
Name:BRUCE H PALEY PA
Entity Type:Organization
Organization Name:BRUCE H PALEY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PA
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:PALEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-824-8088
Mailing Address - Street 1:1851 OLD MOULTRIE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-4168
Mailing Address - Country:US
Mailing Address - Phone:904-824-8088
Mailing Address - Fax:904-826-4105
Practice Address - Street 1:1851 OLD MOULTRIE RD
Practice Address - Street 2:SUITE B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4168
Practice Address - Country:US
Practice Address - Phone:904-824-8088
Practice Address - Fax:904-826-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5622207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371938300Medicaid
4394237OtherAETNA
80532OtherBLUE CROSS
070005035OtherRAILROAD MEDICARE
101894OtherAVMED
4394237OtherAETNA
101894OtherAVMED