MEDICARE: DR. JACK BRUDER 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	208800000X	Urology Physician	155544	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01156G	OTHER		MEDICARE GHI
5	52313	OTHER		GHI MEDICARE CHOICE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
2	0011594	OTHER	GHI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	113945	OTHER	AETNA
6	1900573	OTHER	UNITED HEALTHCARE
7	NS1506	OTHER	OXFORD HEALTH PLANS

General Provider Information

NPI Number	:	1518974328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK BRUDER M.D.

Provider Business Mailing Address
First Line	:	50 E 42ND ST RM 508
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10017-5436
Country	:	US
Telephone Number	:	212-661-7003
Fax Number	:	212-661-7005

Provider Business Practice Location Address
First Line	:	50 E 42ND ST RM 508
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10017-5436
Country	:	US
Telephone Number	:	212-661-7003
Fax Number	:	212-661-7005

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	05/09/2022

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Directions to “ DR. JACK BRUDER M.D.” Practice Location

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