Healthcare Provider Details

I. General information

NPI: 1780837534
Provider Name (Legal Business Name): PETER JOSEPH BRUGER PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 CAMPBELL BLVD SUITE 106
WHITE MARSH MD
21162-5500
US

IV. Provider business mailing address

5430 CAMPBELL BLVD SUITE 106
WHITE MARSH MD
21162-5500
US

V. Phone/Fax

Practice location:
  • Phone: 443-725-4930
  • Fax: 443-725-4933
Mailing address:
  • Phone: 443-725-4930
  • Fax: 443-725-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC03868
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: