MEDICARE: DR. BRUCE LYLE TETIRICK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	35042511	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00149781	OTHER	OH	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	288089	OTHER	OH	AMERIGROUP
2	720619	OTHER	OH	UNITED HEALTHCARE
4	000000021056	OTHER	OH	ANTHEM
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	31157505137	OTHER	OH	CARESOURCE
7	990127	OTHER	OH	AETNA

General Provider Information

NPI Number	:	1518960830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE LYLE TETIRICK M.D.

Provider Business Mailing Address
First Line	:	2060 READING RD
Second Line	:	SUITE 150
City	:	CINCINNATI
State	:	OH
Zip	:	45202-1454
Country	:	US
Telephone Number	:	513-721-3200
Fax Number	:	513-639-3186

Provider Business Practice Location Address
First Line	:	9312 WINTON RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45231-3938
Country	:	US
Telephone Number	:	513-922-0009
Fax Number	:	513-931-2481

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	07/31/2015

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