MEDICARE: BRUCE ROGER MCMULLEN MD

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	207R00000X	Internal Medicine Physician	0418744	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	0004084117	OTHER	AETNA INS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	110004044	OTHER	PALMETTO GBA RAILROAD MED

General Provider Information

NPI Number	:	1073574562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE ROGER MCMULLEN MD

Provider Business Mailing Address
First Line	:	1122 SOUTH CLIFTON
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67218-2913
Country	:	US
Telephone Number	:	316-682-5012
Fax Number	:	316-652-9510

Provider Business Practice Location Address
First Line	:	1122 SOUTH CLIFTON
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67218-2913
Country	:	US
Telephone Number	:	316-682-5012
Fax Number	:	316-652-9510

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2006
Last Update Date	:	01/08/2010

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