1417178443 NPI number — MR. TODD HAROLD BRUSS ATC, LAT, CSCS, PA-C

Table of content: MR. TODD HAROLD BRUSS ATC, LAT, CSCS, PA-C (NPI 1417178443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417178443 NPI number — MR. TODD HAROLD BRUSS ATC, LAT, CSCS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUSS
Provider First Name:
TODD
Provider Middle Name:
HAROLD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC, LAT, CSCS, PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417178443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1035 KEPLER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54311-8320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-490-9046
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 KEPLER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54311-8306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-288-5555
Provider Business Practice Location Address Fax Number:
920-288-5550
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  3058 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2255A2300X , with the licence number: 350-039 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1417178443 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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