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NPI Code Detail

MEDICARE: BRUCE EDWARD MALCOLM PSYD

MEDICARE: BRUCE EDWARD MALCOLM PSYD
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
1103TC0700XClinical Psychologist7105OH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1680H215160OTHERMIBC/BS OF MICHIGAN
23218695674OTHERMIPPOM
3382695674OTHERMIVALUE OPTIONS
4371354712OTHERMIMAGELLAN

General Provider Information

NPI Number : 1740480755
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRUCE EDWARD MALCOLM PSYD
Provider Business Mailing Address
First Line : 2121 KEVIN CT NE
Second Line :
City : NEW PHILADELPHIA
State : OH
Zip : 44663-9446
Country : US
Telephone Number : 330-401-5244
Fax Number :
Provider Business Practice Location Address
First Line : 3593 MEDINA RD # 181
Second Line :
City : MEDINA
State : OH
Zip : 44256-8182
Country : US
Telephone Number : 330-401-5244
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/19/2007
Last Update Date : 03/29/2022

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Directions to “ BRUCE EDWARD MALCOLM PSYD” Practice Location

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