Provider Demographics
NPI:1013275031
Name:BRUCE HERRINGTON MD PC
Entity Type:Organization
Organization Name:BRUCE HERRINGTON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:HERRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-482-2993
Mailing Address - Street 1:116 W THIGPEN AVE
Mailing Address - Street 2:STE B
Mailing Address - City:LAKELAND
Mailing Address - State:GA
Mailing Address - Zip Code:31635-1011
Mailing Address - Country:US
Mailing Address - Phone:229-482-2993
Mailing Address - Fax:229-482-2998
Practice Address - Street 1:116 W THIGPEN AVE
Practice Address - Street 2:STE B
Practice Address - City:LAKELAND
Practice Address - State:GA
Practice Address - Zip Code:31635-1011
Practice Address - Country:US
Practice Address - Phone:229-482-2993
Practice Address - Fax:229-482-2998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046118207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000869701EMedicaid
GAH20723Medicare UPIN