Provider Demographics
NPI:1346257821
Name:BRUNT, CHARLES HAL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HAL
Last Name:BRUNT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1000 DEPT 0510
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38133-0510
Mailing Address - Country:US
Mailing Address - Phone:901-821-0338
Mailing Address - Fax:901-821-0341
Practice Address - Street 1:2911 BRUNSWICK RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38133
Practice Address - Country:US
Practice Address - Phone:901-821-0338
Practice Address - Fax:901-507-8298
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0094542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3159926Medicaid
TNQ027409Medicaid
TN2005394OtherBCBS
MS14899Medicaid
TN3382895Medicare ID - Type UnspecifiedMEDICARE
TN2005394OtherBCBS