Healthcare Provider Details

I. General information

NPI: 1093791600
Provider Name (Legal Business Name): BRUCE CUSHMAN GEBHARDT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 SASSAFRAS ST SUITE 200
ERIE PA
16502-2722
US

IV. Provider business mailing address

3530 PEACH ST SUITE LL1
ERIE PA
16508-2768
US

V. Phone/Fax

Practice location:
  • Phone: 814-454-4484
  • Fax: 814-452-1809
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35068061
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD044328E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: