MEDICARE: BRUCE WILLNER DO LLC

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34-004681	OTHER	OH	LIC #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730664558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUCE WILLNER DO LLC

Provider Business Mailing Address
First Line	:	3622 BELMONT AVE STE 18
Second Line	:
City	:	YOUNGSTOWN
State	:	OH
Zip	:	44505-1444
Country	:	US
Telephone Number	:	330-759-8050
Fax Number	:	330-759-1246

Provider Business Practice Location Address
First Line	:	3622 BELMONT AVE STE 18
Second Line	:
City	:	YOUNGSTOWN
State	:	OH
Zip	:	44505-1444
Country	:	US
Telephone Number	:	330-759-8050
Fax Number	:	330-759-1246

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	BRUCE WILLNER
Credential	:	DO
Telephone Number	:	330-759-8050

Provider Enumeration Date	:	09/27/2018
Last Update Date	:	09/27/2018

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