Healthcare Provider Details

I. General information

NPI: 1396795407
Provider Name (Legal Business Name): BRUCE P CONMY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 WASHINGTON AVE
DETROIT LAKES MN
56501-3409
US

IV. Provider business mailing address

1027 WASHINGTON AVE
DETROIT LAKES MN
56501-3409
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-5611
  • Fax: 218-847-0881
Mailing address:
  • Phone: 218-847-5611
  • Fax: 218-847-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number29133
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4645
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: