1689758237 NPI number — JEANINE L BRUNCLIK M.D.

Table of content: JEANINE L BRUNCLIK M.D. (NPI 1689758237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689758237 NPI number — JEANINE L BRUNCLIK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNCLIK
Provider First Name:
JEANINE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1689758237
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
235 STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CROIX FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54024-4117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-483-3221
Provider Business Mailing Address Fax Number:
715-483-0507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
235 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT CROIX FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54024-4117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-483-3221
Provider Business Practice Location Address Fax Number:
715-483-0507
Provider Enumeration Date:
10/24/2006

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: 207Q00000X , with the licence number:  49004 , 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: 389435600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080H9BR . This is a "BCBS MN PRO FEE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 34840300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01-23254 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: NA9031046087 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 501S5BR . This is a "BCBS MN FACILITY" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP58527 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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