Provider Demographics
NPI:1699974808
Name:JOHN L BRUSCH MD,PC
Entity type:Organization
Organization Name:JOHN L BRUSCH MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PC
Authorized Official - Phone:617-665-1511
Mailing Address - Street 1:1493 CAMBRIDGE ST
Mailing Address - Street 2:ROOM 779
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1047
Mailing Address - Country:US
Mailing Address - Phone:617-665-1511
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:ROOM 779
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1047
Practice Address - Country:US
Practice Address - Phone:617-665-1511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM12752OtherBLUE SHIELD
MA9728589Medicaid
MAD82736Medicare UPIN