Provider Demographics
NPI:1245236793
Name:BRUNNER, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:BRUNNER
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 1:1221 SIXTH ST STE 208
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2360
Mailing Address - Country:US
Mailing Address - Phone:231-935-2045
Mailing Address - Fax:231-935-3420
Practice Address - Street 1:1221 SIXTH ST STE 208
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2360
Practice Address - Country:US
Practice Address - Phone:231-935-2045
Practice Address - Fax:231-935-3420
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044585207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00722OtherPARAMOUNT
OH460003221OtherMEDICARE RR
OH000000203481OtherANTHEM
OH100187OtherPHYSICIANS HEALTH COLLABERATIVE
OH0735673Medicaid
OH600489OtherBUCKEYE
OH4095569OtherAETNA
MI4340207(10)0OtherMICHIGAN MEDICAID
OH600489OtherBUCKEYE
OH0735673Medicaid
OHBR0543064Medicare ID - Type Unspecified
OH460003221OtherMEDICARE RR