Provider Demographics
NPI:1114902590
Name:BRUNER, PHILLIP MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:MARK
Last Name:BRUNER
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 1:418 E POLK ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52353-1237
Mailing Address - Country:US
Mailing Address - Phone:319-653-2229
Mailing Address - Fax:319-653-5040
Practice Address - Street 1:418 E POLK ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IA
Practice Address - Zip Code:52353-1237
Practice Address - Country:US
Practice Address - Phone:319-653-2229
Practice Address - Fax:319-653-5040
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62537174400000X
IAMD-42240207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL198234OtherHEALTHEASE
208117OtherAVMED
00162435OtherRAILROAD MEDICARE
3456144OtherAETNA
FL370763600Medicaid
FL17750OtherBLUE SHIELD
208117OtherAVMED
E72625Medicare UPIN