Provider Demographics
NPI:1588615330
Name:GRUNERT, BRAD (PHD)
Entity Type:Individual
Prefix:MS
First Name:BRAD
Middle Name:
Last Name:GRUNERT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF PLASTIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5858
Mailing Address - Fax:414-805-5850
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF PLASTIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5858
Practice Address - Fax:414-805-5850
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI921103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000220GOtherHUMANA
WI1588615330Medicaid
002000220GOtherHUMANA
WI68086 0673Medicare PIN
WI07520 0049Medicare PIN
WI1588615330Medicaid