1023497740 NPI number — DR. LARRY MICHAEL BRUNI MD

Table of content: DR. LARRY MICHAEL BRUNI MD (NPI 1023497740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023497740 NPI number — DR. LARRY MICHAEL BRUNI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNI
Provider First Name:
LARRY
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1023497740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 PARTRIDGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12208-2939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-812-4899
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 PINNACLE PL
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12203-3496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-360-1011
Provider Business Practice Location Address Fax Number:
518-278-4417
Provider Enumeration Date:
05/27/2015

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: 207R00000X , with the licence number:  275946 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 0101-037258 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0101-037258 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 275946 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: XB5078236 . This is a "DATA 2000 WAIVER" identifier . This identifiers is of the category "OTHER".




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