Provider Demographics
NPI:1316945983
Name:ACKERMAN, BRUCE IRWIN (DPM)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:IRWIN
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 WELSH ROAD
Mailing Address - Street 2:STE 21 #240
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1509
Mailing Address - Country:US
Mailing Address - Phone:215-334-5700
Mailing Address - Fax:
Practice Address - Street 1:2417 WELSH ROAD
Practice Address - Street 2:SUITE 21 #240
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114
Practice Address - Country:US
Practice Address - Phone:215-334-5700
Practice Address - Fax:215-334-5774
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002030L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5677430OtherAETNA INSURANCE ID#
PASC002030L15493Medicaid
PA0054016601Medicaid
PA0060614000OtherINDEPENDENCE BLUE CROSS
PA0060614000Medicare ID - Type UnspecifiedINDEPENDENCE BLUE CROSS
PAT28749Medicare UPIN
PA109115Medicare ID - Type UnspecifiedHIGHMARK MEDICARE
PASC002030L15493Medicaid
PA5677430OtherAETNA INSURANCE ID#