Provider Demographics
NPI:1780677682
Name:BRUCE H WELLMON DPM PA
Entity Type:Organization
Organization Name:BRUCE H WELLMON DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WELLMON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:864-487-5516
Mailing Address - Street 1:PO BOX 1436
Mailing Address - Street 2:
Mailing Address - City:GAFFNEY
Mailing Address - State:SC
Mailing Address - Zip Code:29342-1436
Mailing Address - Country:US
Mailing Address - Phone:864-487-5516
Mailing Address - Fax:864-487-3477
Practice Address - Street 1:101 PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29340-2319
Practice Address - Country:US
Practice Address - Phone:864-487-5516
Practice Address - Fax:864-487-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86213E00000X
NC216213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9937Medicaid
SC4518130001Medicare NSC
NC8908156Medicare PIN
SC7289Medicare PIN