MEDICARE: ALEX HARRY BRUCKSTEIN 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	207RG0100X	Gastroenterology Physician	NY129764	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	325101	OTHER	NY	MEDICARE PTAN

General Provider Information

NPI Number	:	1114971835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEX HARRY BRUCKSTEIN MD

Provider Business Mailing Address
First Line	:	2627 HYLAN BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-4339
Country	:	US
Telephone Number	:	718-667-3200
Fax Number	:	718-667-6615

Provider Business Practice Location Address
First Line	:	2627 HYLAN BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-4339
Country	:	US
Telephone Number	:	718-667-3200
Fax Number	:	718-667-6615

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

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	05/05/2010

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