MEDICARE: DR. BRUCE JOSEPH SIEDLECKI M.D.

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	207V00000X	Obstetrics & Gynecology Physician	MD25309	TN

General Provider Information

NPI Number	:	1285628156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE JOSEPH SIEDLECKI M.D.

Provider Business Mailing Address
First Line	:	1050 NW BLUEGRASS CIR
Second Line	:
City	:	MTN HOME
State	:	ID
Zip	:	83647-1544
Country	:	US
Telephone Number	:	208-828-7567
Fax Number	:

Provider Business Practice Location Address
First Line	:	MTN.HOME AIF FORCE BASE
Second Line	:	MDOS
City	:	MTN. HOME
State	:	ID
Zip	:	83647
Country	:	US
Telephone Number	:	208-828-7567
Fax Number	:

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/08/2007

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