Healthcare Provider Details

I. General information

NPI: 1447200704
Provider Name (Legal Business Name): BRUCE WILLHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 M L KING JR WAY ATTN: PEDIATRIX MEDICAL GROUP
TACOMA WA
98405-4234
US

IV. Provider business mailing address

315 M L KING JR WAY ATTN: PEDIATRIX MEDICAL GROUP
TACOMA WA
98405-4234
US

V. Phone/Fax

Practice location:
  • Phone: 253-403-1019
  • Fax:
Mailing address:
  • Phone: 253-403-1019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number22636
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: