Provider Demographics
NPI:1568649283
Name:BROMAN, BRUCE W (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:BROMAN
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 1:251 COUNTY RD 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4665
Mailing Address - Country:US
Mailing Address - Phone:320-202-8949
Mailing Address - Fax:
Practice Address - Street 1:1301 33RD ST S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-9668
Practice Address - Country:US
Practice Address - Phone:320-251-8181
Practice Address - Fax:320-251-6942
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2010-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35592208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO014014700Medicaid
MN379000274Medicare PIN
MO014014700Medicaid