Provider Demographics
NPI:1700336781
Name:RUCH, BRADLEY S (NP-C)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:S
Last Name:RUCH
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11528 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-1442
Mailing Address - Country:US
Mailing Address - Phone:727-868-2151
Mailing Address - Fax:
Practice Address - Street 1:11528 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-1442
Practice Address - Country:US
Practice Address - Phone:727-868-2151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2019-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020108363LF0000X
MI4704325400363LF0000X
FLAPRN9488436363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1700336781Medicaid
OHPENDINGMedicaid
MIP18010007Medicare PIN