MEDICARE: R BRUCE PRINCE MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	012360	GA

General Provider Information

NPI Number	:	1043579212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R BRUCE PRINCE MD PC

Provider Business Mailing Address
First Line	:	1945 CLIFF VALLEY WAY NE
Second Line	:	SUITE 260
City	:	ATLANTA
State	:	GA
Zip	:	30329-2477
Country	:	US
Telephone Number	:	404-634-1195
Fax Number	:	404-321-3987

Provider Business Practice Location Address
First Line	:	1945 CLIFF VALLEY WAY NE
Second Line	:	SUITE 260
City	:	ATLANTA
State	:	GA
Zip	:	30329-2477
Country	:	US
Telephone Number	:	404-634-1195
Fax Number	:	404-321-3987

Authorized Official
Title or Position	:	OWNER/PHYSICAN
Name	:	DR. R BRUCE PRINCE
Credential	:	M.D.
Telephone Number	:	404-634-1195

Provider Enumeration Date	:	05/09/2012
Last Update Date	:	05/09/2012

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