1427083963 NPI number — BRYAN E BRUNS MD A MEDICAL CORP

Table of content: (NPI 1427083963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427083963 NPI number — BRYAN E BRUNS MD A MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRYAN E BRUNS MD A MEDICAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1427083963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 511278
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90051-7833
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-284-2771
Provider Business Mailing Address Fax Number:
800-334-1041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9255 TOWNE CENTRE DR
Provider Second Line Business Practice Location Address:
SUITE 370
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-3033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-535-0091
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNS
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-535-0091

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  G29642 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00G296420 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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