Healthcare Provider Details

I. General information

NPI: 1235102062
Provider Name (Legal Business Name): DARREN C BRUCKEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 E COURT ST
PARIS IL
61944-2460
US

IV. Provider business mailing address

721 E COURT ST
PARIS IL
61944-2420
US

V. Phone/Fax

Practice location:
  • Phone: 217-465-4141
  • Fax: 812-299-3263
Mailing address:
  • Phone: 217-465-4141
  • Fax: 217-465-5615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036159332
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01049016A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: