Provider Demographics
NPI:1730141789
Name:BRUNCK, DAVID G (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:BRUNCK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 TECHNOLOGY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-8548
Mailing Address - Country:US
Mailing Address - Phone:812-941-4500
Mailing Address - Fax:812-542-1904
Practice Address - Street 1:4101 TECHNOLOGY AVE
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-8548
Practice Address - Country:US
Practice Address - Phone:812-941-4500
Practice Address - Fax:812-542-1904
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000682A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN210410DMedicare ID - Type Unspecified
S96255Medicare UPIN