Provider Demographics
NPI:1518237049
Name:RICHARD R BRUNELLE MD, PA
Entity Type:Organization
Organization Name:RICHARD R BRUNELLE MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRUNELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-873-1850
Mailing Address - Street 1:508 S HABANA AVE
Mailing Address - Street 2:SUITE 370
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4181
Mailing Address - Country:US
Mailing Address - Phone:813-873-1850
Mailing Address - Fax:813-873-8046
Practice Address - Street 1:508 S HABANA AVE
Practice Address - Street 2:SUITE 370
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4181
Practice Address - Country:US
Practice Address - Phone:813-873-1850
Practice Address - Fax:813-873-8046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25656174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78471Medicare PIN