1316961238 NPI number — MICHAEL R BRUNO MD

Table of content: MICHAEL R BRUNO MD (NPI 1316961238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316961238 NPI number — MICHAEL R BRUNO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNO
Provider First Name:
MICHAEL
Provider Middle Name:
R
Provider Name Prefix Text:
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:
1316961238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 50770
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82605-0770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-333-6910
Provider Business Mailing Address Fax Number:
307-333-6912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1233 E 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82601-2926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-333-6910
Provider Business Practice Location Address Fax Number:
307-333-6912
Provider Enumeration Date:
07/26/2006

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: 207P00000X , with the licence number:  4186A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104863500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 930013243 . This is a "RAILRAOD MEDICARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 305752 . This is a "BLUE SHIELD" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 82601D022 . This is a "WPS TRIWEST" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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