Provider Demographics
NPI:1255465043
Name:BRUNI PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:BRUNI PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRUNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-864-7747
Mailing Address - Street 1:9454 THREE RIVERS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4294
Mailing Address - Country:US
Mailing Address - Phone:228-864-7747
Mailing Address - Fax:228-864-7415
Practice Address - Street 1:9454 THREE RIVERS RD
Practice Address - Street 2:SUITE A
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4294
Practice Address - Country:US
Practice Address - Phone:228-864-7747
Practice Address - Fax:228-864-7415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015616Medicaid