MEDICARE: BRADENTON EAST MEDICAL PA

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		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21621	OTHER	FL	BCBS FLORIDA GROUP NUMBER

General Provider Information

NPI Number	:	1861589467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADENTON EAST MEDICAL PA

Provider Business Mailing Address
First Line	:	6120 53RD AVE E
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34203-9707
Country	:	US
Telephone Number	:	941-727-1243
Fax Number	:

Provider Business Practice Location Address
First Line	:	6120 53RD AVE E
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34203-9707
Country	:	US
Telephone Number	:	941-727-1243
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ELSY RUCKER
Credential	:	M.D.
Telephone Number	:	941-727-1243

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	08/22/2020

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1588658496 — DR. LAURA L. HERSHORIN M.D.
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1265422430 — DR. ELSY RUCKER M.D.
Practice Location Address:

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34203-9707

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1508801671 — THOMAS L. PROSSER P.A.
Practice Location Address:

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1629009089 — GEORGE BINO RUCKER M.D.
Practice Location Address:

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1871680090 — SUNCOAST ALLERGY & ASTHMA CENTER
Practice Location Address:

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Directions to “BRADENTON EAST MEDICAL PA ” Practice Location

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