Basic Information
| Provider Information | |||||||||
| NPI: | 1396795407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONMY | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 12/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 29133 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 4645 | ND | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0703070 | 01 | MN | MEDICA | OTHER | 585240896131 | 01 | MN | PREFERRED ONE | OTHER | 1396795407 | 05 | MN | MEDICAID | 189P8C0 | 01 | MN | BC BS | OTHER | 614072600 | 05 | MN | MEDICAID |