Healthcare Provider Details

I. General information

NPI: 1205977352
Provider Name (Legal Business Name): ANDREA KATHRYN BRUSS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WATERVILLE MONCLOVA RD SUITE A
WATERVILLE OH
43566-1168
US

IV. Provider business mailing address

4308 RUGBY DR
TOLEDO OH
43614-5633
US

V. Phone/Fax

Practice location:
  • Phone: 419-878-3010
  • Fax: 419-878-3236
Mailing address:
  • Phone: 419-389-1113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number89211
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: