Provider Demographics
NPI:1841283033
Name:STALEY, BRUCE EDMUND (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EDMUND
Last Name:STALEY
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 1:891 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2118
Mailing Address - Country:US
Mailing Address - Phone:937-382-5030
Mailing Address - Fax:937-655-8390
Practice Address - Street 1:891 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2118
Practice Address - Country:US
Practice Address - Phone:937-382-5030
Practice Address - Fax:937-655-8390
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046235S207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0420218OtherUNITED HEALTHCARE
46235OtherHUMANA CHOICE CARE
00000020491OtherIRON WORKERS BENEFIT TRUS
0014450OtherTRICARE FOR LIFE
OH000000020491OtherANTHEM
OH0551451Medicaid
OHIN9287051OtherMEDICARE GROUP
C03150Medicare UPIN
OHST0592583Medicare PIN
OH0551451Medicaid
OH110138708Medicare PIN
OH110114323Medicare PIN