Provider Demographics
NPI:1316109564
Name:BRUCKNER, ADAM W (DO)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:W
Last Name:BRUCKNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:367 S. GULPH RD
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:803-649-7266
Mailing Address - Fax:
Practice Address - Street 1:420 SOCIETY HILL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-1731
Practice Address - Country:US
Practice Address - Phone:803-649-7266
Practice Address - Fax:803-649-7158
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2019-02-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC1639207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC016397Medicaid
SC016397Medicaid