Provider Demographics
NPI:1447202023
Name:BRUCH, JOHN STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STEVEN
Last Name:BRUCH
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4296
Practice Address - Country:US
Practice Address - Phone:864-455-9031
Practice Address - Fax:864-455-9014
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20384207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN34256Medicaid
SC110176775OtherRR MEDICARE
SCP00797727OtherRR MEDICARE
SC110176775OtherRR MEDICARE
SCN34256Medicaid