Provider Demographics
NPI:1255869426
Name:BRUNO, MICHAEL ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:BRUNO
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 1:3401 CIVIC CENTER BLVD RM 55
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4319
Mailing Address - Country:US
Mailing Address - Phone:215-590-1220
Mailing Address - Fax:
Practice Address - Street 1:6651 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2351
Practice Address - Country:US
Practice Address - Phone:832-824-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT212744208000000X
TXS6140208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA9404718760Medicaid