Provider Demographics
NPI:1730664558
Name:BRUCE WILLNER DO LLC
Entity type:Organization
Organization Name:BRUCE WILLNER DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-759-8050
Mailing Address - Street 1:3622 BELMONT AVE STE 18
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1444
Mailing Address - Country:US
Mailing Address - Phone:330-759-8050
Mailing Address - Fax:330-759-1246
Practice Address - Street 1:3622 BELMONT AVE STE 18
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1444
Practice Address - Country:US
Practice Address - Phone:330-759-8050
Practice Address - Fax:330-759-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-004681OtherLIC #
OH0791899Medicaid