Provider Demographics
NPI:1518960830
Name:TETIRICK, BRUCE LYLE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LYLE
Last Name:TETIRICK
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 1:2060 READING RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1454
Mailing Address - Country:US
Mailing Address - Phone:513-721-3200
Mailing Address - Fax:513-639-3186
Practice Address - Street 1:9312 WINTON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-3938
Practice Address - Country:US
Practice Address - Phone:513-922-0009
Practice Address - Fax:513-931-2481
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042511207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH288089OtherAMERIGROUP
OH720619OtherUNITED HEALTHCARE
OHP00149781OtherMEDICARE RAILROAD
OH000000021056OtherANTHEM
OH0580625Medicaid
OH31157505137OtherCARESOURCE
OH990127OtherAETNA
OH990127OtherAETNA
OH0580625Medicaid
OH000000021056OtherANTHEM
OH720619OtherUNITED HEALTHCARE