Provider Demographics
NPI:1639138449
Name:BRUSCH, JOHN L (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:BRUSCH
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 1:1493 CAMBRIDGE ST
Mailing Address - Street 2:CAHILL BUILDING ROOM C220 2ND FLOOR
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1047
Mailing Address - Country:US
Mailing Address - Phone:617-661-1800
Mailing Address - Fax:617-661-7416
Practice Address - Street 1:1493 CAMBRIDGE STREET CAHILL BUILDING
Practice Address - Street 2:CAMBRIDGE HOSPITAL
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-661-1800
Practice Address - Fax:617-661-7416
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32675207R00000X, 207RG0300X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB02101OtherBLUE CROSS
MA9728589Medicaid
MA032675OtherTUFTS HEALTH PLAN
M12752Medicare ID - Type Unspecified
D82736Medicare UPIN