Provider Demographics
NPI:1649574054
Name:E BRUNS FOOT AND ANKLE SC
Entity Type:Organization
Organization Name:E BRUNS FOOT AND ANKLE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:BRUNS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-248-9565
Mailing Address - Street 1:160 E GENEVA SQ
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-9694
Mailing Address - Country:US
Mailing Address - Phone:262-248-9565
Mailing Address - Fax:262-248-0065
Practice Address - Street 1:3805B SPRING ST
Practice Address - Street 2:SUITE 340
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1641
Practice Address - Country:US
Practice Address - Phone:262-248-9565
Practice Address - Fax:262-248-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI648-025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43215500Medicaid
WI1821140864Medicare NSC
WIU05237Medicare UPIN
WI43215500Medicaid