Provider Demographics
NPI:1982764684
Name:BRUCE PIERSON JR MD PC
Entity Type:Organization
Organization Name:BRUCE PIERSON JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PIERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:304-424-4640
Mailing Address - Street 1:600 18TH STREET
Mailing Address - Street 2:SUITE 311
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101
Mailing Address - Country:US
Mailing Address - Phone:304-424-4640
Mailing Address - Fax:304-424-4628
Practice Address - Street 1:600 18TH STREET
Practice Address - Street 2:SUITE 311
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101
Practice Address - Country:US
Practice Address - Phone:304-424-4640
Practice Address - Fax:304-424-4628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10635207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0296979OtherOH MEDICAID
WV3810009741Medicaid
DG2883OtherRR MEDICARE
OH0296979OtherOH MEDICAID
A71928Medicare UPIN