Provider Demographics
NPI:1972563229
Name:HYMANSON, BRUCE H (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:H
Last Name:HYMANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 10TH AVE APT 38A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-3062
Mailing Address - Country:US
Mailing Address - Phone:773-919-3919
Mailing Address - Fax:
Practice Address - Street 1:561 10TH AVE APT 38A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-3062
Practice Address - Country:US
Practice Address - Phone:773-919-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057124207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057124Medicaid
IL681720Medicare ID - Type Unspecified
IL036057124Medicaid