Provider Demographics
NPI:1356530190
Name:BRUCE A PECKAGE DPM PC
Entity type:Organization
Organization Name:BRUCE A PECKAGE DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PECKAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:518-438-3544
Mailing Address - Street 1:995 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-1611
Mailing Address - Country:US
Mailing Address - Phone:518-438-3544
Mailing Address - Fax:518-438-4292
Practice Address - Street 1:995 STATE ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1611
Practice Address - Country:US
Practice Address - Phone:518-438-3544
Practice Address - Fax:518-438-4292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
NYN002732213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00401890Medicaid
NYCM7254Medicare PIN
NY00401890Medicaid
NY50550AMedicare PIN