Provider Demographics
NPI:1710067962
Name:JORGE E BRUNELLE, MD, MPH, PC
Entity Type:Organization
Organization Name:JORGE E BRUNELLE, MD, MPH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRUNELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH, PC
Authorized Official - Phone:630-801-4150
Mailing Address - Street 1:120 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505-4228
Mailing Address - Country:US
Mailing Address - Phone:630-801-4150
Mailing Address - Fax:630-801-4151
Practice Address - Street 1:120 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-4228
Practice Address - Country:US
Practice Address - Phone:630-801-4150
Practice Address - Fax:630-801-4151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0036-097428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0036-097428OtherLICENSE NUMBER
IL36097428Medicaid
IL36097428Medicaid
IL531250Medicare ID - Type Unspecified5/1/99