Provider Demographics
NPI:1013044700
Name:BRUNER, ANN BENNETT (MD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:BENNETT
Last Name:BRUNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 FALLSCROFT WAY
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-1705
Mailing Address - Country:US
Mailing Address - Phone:410-308-3179
Mailing Address - Fax:
Practice Address - Street 1:MOUNTAIN MANOR TREATMENT CENTER
Practice Address - Street 2:3800 FREDERICK AVENUE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:410-233-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD41505208000000X, 2080A0000X
DCMD31948208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E97523Medicare UPIN