Provider Demographics
NPI:1205855715
Name:BRUNS, EDWARD A (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:BRUNS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402
Mailing Address - Country:US
Mailing Address - Phone:573-458-3425
Mailing Address - Fax:573-426-2282
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:STE 350
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-458-3350
Practice Address - Fax:573-426-6247
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO31589207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00144896OtherRAIL ROAD MEDICARE
MO240502815Medicaid
MO24052815Medicaid
MO8768OtherBLUE CROSS BLUE SHIELD OF
MO130959OtherHEALTHLINK
MO130959OtherHEALTHLINK
MOF46029Medicare UPIN