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General NPI Number Information
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NPI Number | 1033370762
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Entity Type | Organization
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Legal Business Name | BENNETT H. BRUCKNER,M.D., P.C.
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Dates
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Enumeration Date | 06/25/2008
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Last Update Date | 06/25/2008
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Provider Practice Location Address
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Address Line | 575 PROFESSIONAL DR SUITE 290
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-3333
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Country | US
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Telephone | 770-962-9410
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Fax | 770-962-8489
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Provider Business Mailing Address
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Address Line | 575 PROFESSIONAL DR SUITE 290
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-3333
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Country | US
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Telephone | 770-962-9410
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Fax | 770-962-8489
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. BENNETT HOWARD BRUCKNER
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Credential | M.D.
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Telephone | 770-962-9410
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 034547
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License Number State | GA
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