1649574054 NPI number — E BRUNS FOOT AND ANKLE SC

Table of content: (NPI 1649574054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649574054 NPI number — E BRUNS FOOT AND ANKLE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E BRUNS FOOT AND ANKLE SC
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:
1649574054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 E GENEVA SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE GENEVA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53147-9694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-248-9565
Provider Business Mailing Address Fax Number:
262-248-0065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3805B SPRING ST
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
RACINE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53405-1641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-248-9565
Provider Business Practice Location Address Fax Number:
262-248-0065
Provider Enumeration Date:
12/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
CARL
Authorized Official Title or Position:
SOLO PRACTITIONER
Authorized Official Telephone Number:
262-248-9565

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  648-025 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 43215500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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