Healthcare Provider Details

I. General information

NPI: 1073888731
Provider Name (Legal Business Name): BRUCE ALAN GRADOLPH R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

V. Phone/Fax

Practice location:
  • Phone: 734-769-7100
  • Fax: 734-845-3296
Mailing address:
  • Phone: 734-769-7100
  • Fax: 734-845-3296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704193798
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number4704193798
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704193798
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: