Healthcare Provider Details

I. General information

NPI: 1174519805
Provider Name (Legal Business Name): BRUCE ELVON RICE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5398 PARK ST N
ST PETERSBURG FL
33709-1041
US

IV. Provider business mailing address

5398 PARK ST N
ST PETERSBURG FL
33709-1041
US

V. Phone/Fax

Practice location:
  • Phone: 727-544-1441
  • Fax: 727-545-8263
Mailing address:
  • Phone: 727-544-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: