Provider Demographics
NPI:1114946738
Name:BRUNETTI, MARISSA A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:A
Last Name:BRUNETTI
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 1:100 E PENN SQ
Mailing Address - Street 2:THE WANAMAKER BUILDING, 9TH FLOOR, NORTH
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9300
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:800-243-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD63275208000000X
PAMD4399812080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026270630001Medicaid
MDKJ50GB/64687801OtherCAREFIRST MARYLAND GBMC
MDS1390049OtherCAREFIRST REGIONAL GBMC
MD409240600Medicaid
PA226140EMDOtherMEDICARE PTAN