Provider Demographics
NPI:1639270622
Name:BRUCKNER, BENNETT HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:HOWARD
Last Name:BRUCKNER
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:11 DOCTORS PARK DR STE 240
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1008
Practice Address - Country:US
Practice Address - Phone:864-342-4115
Practice Address - Fax:864-342-4064
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034547207RG0100X
SC36622207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00473228AMedicaid
SC366222Medicaid
SCSC34105206OtherMEDICARE PIN