Provider Demographics
NPI:1689758237
Name:BRUNCLIK, JEANINE L (MD)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:L
Last Name:BRUNCLIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3221
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:235 STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-4117
Practice Address - Country:US
Practice Address - Phone:715-483-3221
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN389435600Medicaid
MN080H9BROtherBCBS MN PRO FEE
WI34840300Medicaid
MN01-23254OtherMEDICA
MNNA9031046087OtherPREFERRED ONE
MN501S5BROtherBCBS MN FACILITY
MNHP58527OtherHEALTHPARTNERS
WII48368Medicare UPIN
WI004880136Medicare ID - Type Unspecified