Provider Demographics
NPI:1558336065
Name:PECKAGE, BRUCE A (DPM)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:PECKAGE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1048
Mailing Address - Country:US
Mailing Address - Phone:518-438-3544
Mailing Address - Fax:
Practice Address - Street 1:995 STATE ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1611
Practice Address - Country:US
Practice Address - Phone:518-438-3544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-18
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2732213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00401890Medicaid
NY50550BMedicare PIN
NY00401890Medicaid
NY0594090001Medicare NSC
NY50550AMedicare PIN