Provider Demographics
NPI:1083685440
Name:BRUNELLE, CHARLES W (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:W
Last Name:BRUNELLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-4074
Mailing Address - Country:US
Mailing Address - Phone:419-999-1312
Mailing Address - Fax:
Practice Address - Street 1:375 N EASTOWN RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807-2214
Practice Address - Country:US
Practice Address - Phone:419-228-3500
Practice Address - Fax:419-228-6700
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042012207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0361335Medicaid
OHBR0446012Medicare ID - Type Unspecified
OH0361335Medicaid