Provider Demographics
NPI:1578564688
Name:MARSHALL, BRUCE A (MD , PA)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:MD , PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1012 MEDICAL RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-4542
Practice Address - Country:US
Practice Address - Phone:864-833-3852
Practice Address - Fax:864-938-0501
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2018-10-10
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
SC9545208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC095453Medicaid
SC095453Medicaid