Provider Demographics
NPI:1013919729
Name:CASSIDY, BRUCE ALAN (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:CASSIDY
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 102847
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-0001
Mailing Address - Country:US
Mailing Address - Phone:404-352-1994
Mailing Address - Fax:404-352-9361
Practice Address - Street 1:2001 PEACHTREE RD NE
Practice Address - Street 2:SUITE 435
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1476
Practice Address - Country:US
Practice Address - Phone:404-352-1994
Practice Address - Fax:404-352-9361
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17148207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00137563BMedicaid
GA00137563BMedicaid
GA29BDCQVMedicare PIN