1891836276 NPI number — DOUGLAS J. BRUNNER, M. D.

Table of content: (NPI 1891836276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891836276 NPI number — DOUGLAS J. BRUNNER, M. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS J. BRUNNER, M. D.
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:
1891836276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 E CHESTER PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDLEY PARK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19078-2212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-595-6521
Provider Business Mailing Address Fax Number:
610-595-6077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 E CHESTER PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDLEY PARK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19078-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-595-6542
Provider Business Practice Location Address Fax Number:
610-595-6077
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNNER
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
610-595-6521

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  MD027564E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0142329000 . This is a "IBC KEYSTONE/PERS CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 884151 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0009930450002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0099162 . This is a "AETNA USHC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: DA5481 . This is a "TRAVELERS MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30018109 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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