MEDICARE: MR. MICHAEL BRUCE LMT

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	208D00000X	General Practice Physician	MA58190	FL

General Provider Information

NPI Number	:	1629390596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL BRUCE LMT

Provider Business Mailing Address
First Line	:	3904 HUNT RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-1597
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1037 W BUSCH BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33612-7703
Country	:	US
Telephone Number	:	813-868-1212
Fax Number	:

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

Provider Enumeration Date	:	02/19/2010
Last Update Date	:	02/19/2010

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