Provider Demographics
NPI:1639170509
Name:BRUNO, PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
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 1:3535 LEE RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120-5122
Mailing Address - Country:US
Mailing Address - Phone:216-417-6166
Mailing Address - Fax:216-417-8676
Practice Address - Street 1:3535 LEE RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44120-5122
Practice Address - Country:US
Practice Address - Phone:216-417-6166
Practice Address - Fax:216-417-8676
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.096568207V00000X, 207V00000X
OH35096568207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34165000Medicaid
WIF56095Medicare UPIN
WI34165000Medicaid