MEDICARE: DR. ALLEN THOMAS BRUCE MD PHD

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	207N00000X	Dermatology Physician	018852	ME
2	207N00000X	Dermatology Physician	4301083648	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5315017780	OTHER	MI	CONTROLLED SUBSTANCE LICE

General Provider Information

NPI Number	:	1427175934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALLEN THOMAS BRUCE MD PHD

Provider Business Mailing Address
First Line	:	50 SEWALL ST
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04102-2645
Country	:	US
Telephone Number	:	207-775-3526
Fax Number	:	207-775-5658

Provider Business Practice Location Address
First Line	:	50 SEWALL ST
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04102-2645
Country	:	US
Telephone Number	:	207-775-3526
Fax Number	:	207-775-5658

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	12/07/2011

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