Healthcare Provider Details

I. General information

NPI: 1235114547
Provider Name (Legal Business Name): BEAU BENJAMIN BRUCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365B CLIFTON RD NE SUITE B-3600
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

1365B CLIFTON RD NE SUITE B-3600
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-5360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number057783
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: