=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063581833
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE FREDRIC HAUPT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 12/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 CHESTNUT ST
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-766-7515
-----------------------------------------------------
Fax | 304-766-7566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4605 MACCORKLE AVE SW
-----------------------------------------------------
City | SOUTH CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-414-4800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 18234
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 35-06-2182H
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------