Provider Demographics
NPI:1457457830
Name:BRUNO, EDWARD J (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
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 1:25654 PLANTATION ROAD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586
Mailing Address - Country:US
Mailing Address - Phone:815-436-1664
Mailing Address - Fax:
Practice Address - Street 1:333 N MADISON
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60586
Practice Address - Country:US
Practice Address - Phone:815-741-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
9915352OtherBLUE SHIELD
ILN288953OtherHARMONY
IL6124854000OtherDEPARTMENT OF LABOR
IL6124854000OtherDEPARTMENT OF LABOR
ILP00990Medicare PIN