Provider Demographics
NPI:1639270382
Name:GROOM, BRUCE ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:GROOM
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 1:3908 BATESVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120
Mailing Address - Country:US
Mailing Address - Phone:501-529-5045
Mailing Address - Fax:
Practice Address - Street 1:639 LOTUS DRIVE N
Practice Address - Street 2:SUITE B
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70470
Practice Address - Country:US
Practice Address - Phone:985-626-6133
Practice Address - Fax:985-626-6136
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4295207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARC44621Medicare UPIN
AR55221Medicare ID - Type Unspecified