Provider Demographics
NPI:1164830725
Name:BRUNNER SURGICAL
Entity Type:Organization
Organization Name:BRUNNER SURGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRUNNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-209-4576
Mailing Address - Street 1:2919 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-3345
Mailing Address - Country:US
Mailing Address - Phone:850-209-4576
Mailing Address - Fax:850-526-1323
Practice Address - Street 1:4318 5TH AVE
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2182
Practice Address - Country:US
Practice Address - Phone:850-209-4576
Practice Address - Fax:850-526-1323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046858261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02676OtherBCBS
FLD50601Medicare UPIN