Provider Demographics
NPI: | 1518903491 |
---|---|
Name: | MATHERN, BRUCE E (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | BRUCE |
Middle Name: | E |
Last Name: | MATHERN |
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: | BOX 91734 |
Mailing Address - Street 2: | |
Mailing Address - City: | RICHMOND |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 23219-1734 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 804-358-6100 |
Mailing Address - Fax: | 804-342-7619 |
Practice Address - Street 1: | 417 N 11TH ST |
Practice Address - Street 2: | |
Practice Address - City: | RICHMOND |
Practice Address - State: | VA |
Practice Address - Zip Code: | 23298-5002 |
Practice Address - Country: | US |
Practice Address - Phone: | 804-828-9165 |
Practice Address - Fax: | 804-828-0374 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-21 |
Last Update Date: | 2007-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0101052126 | 207T00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207T00000X | Allopathic & Osteopathic Physicians | Neurological Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 6103456 - 541581185 | Medicaid | |
VA | 490032CG09729 | Other | CMS SECTION 1011 MCV PHYS |
VA | 490032CG09729 | Other | CMS SECTION 1011 MCV PHYS |
VA | 140000149 - C03698 | Medicare ID - Type Unspecified | MCV PHYSICIANS |