Provider Demographics
NPI:1710910583
Name:VEST, BRUCE T (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:T
Last Name:VEST
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 1:4411 ALBY ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5916
Mailing Address - Country:US
Mailing Address - Phone:618-474-8052
Mailing Address - Fax:618-474-8054
Practice Address - Street 1:4411 ALBY ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5916
Practice Address - Country:US
Practice Address - Phone:618-474-8052
Practice Address - Fax:618-474-8054
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0325090001Medicare NSC
ILE80210Medicare UPIN