Provider Demographics
NPI:1871520734
Name:HOULE, BRUCE JC (DO)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:JC
Last Name:HOULE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503809
Mailing Address - Street 2:IMALES USA INC
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-3809
Mailing Address - Country:US
Mailing Address - Phone:800-775-9195
Mailing Address - Fax:309-688-5562
Practice Address - Street 1:3333 WEST DEYOUNG
Practice Address - Street 2:HEARTLAND REGIONAL MEDICAL CENTER DEPT OF RADIOLOGY
Practice Address - City:MAKION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-998-7655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
073759OtherHA
IL0360947753Medicaid
BH4359267OtherDEA
ILL90767Medicare ID - Type Unspecified
E25558Medicare UPIN