Provider Demographics
NPI:1568434835
Name:MIRVIS, BRUCE ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERT
Last Name:MIRVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1070 POLARIS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43240-4038
Mailing Address - Country:US
Mailing Address - Phone:614-437-5600
Mailing Address - Fax:614-437-6275
Practice Address - Street 1:1070 POLARIS PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-4038
Practice Address - Country:US
Practice Address - Phone:614-437-5600
Practice Address - Fax:614-437-6275
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301116689208000000X
MO2018042193208000000X
OH35.039260208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0345086Medicaid