1356344626 NPI number — DR. BRIAN B BRUGGEMAN MD

Table of content: DR. BRIAN B BRUGGEMAN MD (NPI 1356344626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356344626 NPI number — DR. BRIAN B BRUGGEMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUGGEMAN
Provider First Name:
BRIAN
Provider Middle Name:
B
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:
1356344626
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14155 N. 83RD AVE
Provider Second Line Business Mailing Address:
SUITE 147
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85381
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-230-2200
Provider Business Mailing Address Fax Number:
208-535-4564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14155 N. 83RD AVE
Provider Second Line Business Practice Location Address:
SUITE 147
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-230-2200
Provider Business Practice Location Address Fax Number:
208-535-4564
Provider Enumeration Date:
05/31/2005

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: 208200000X , with the licence number:  101550 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: M10264 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: 22884 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: 31346 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 784422 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P784422 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1023267895 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 18032746 . This is a "STATE COMP FUND AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1023267895 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8640234 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1023267895 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 31346 . This is a "STATE LICENSE AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: POOOO4401 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 808217900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8607474153011 . This is a "TAX ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0734420 . This is a "BLUE CROSS BLUE SHIELD AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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