Provider Demographics
NPI:1437522216
Name:W. LEE BRUNER MD LLC
Entity Type:Organization
Organization Name:W. LEE BRUNER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARNER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:225-921-6801
Mailing Address - Street 1:8068 GOODWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8068 GOODWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7631
Practice Address - Country:US
Practice Address - Phone:225-921-6801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA014051OtherMEDICAL LICENSE
LA1359335Medicaid
LA014051OtherMEDICAL LICENSE