Provider Demographics
NPI:1831140441
Name:BULLIS, BRENT R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:R
Last Name:BULLIS
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 1:1025 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4752
Mailing Address - Country:US
Mailing Address - Phone:507-625-4031
Mailing Address - Fax:
Practice Address - Street 1:MAYO CLINIC HEALTH SYSTEM MANKATO
Practice Address - Street 2:1025 MARSH ST
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-625-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN397412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN300003206Medicare PIN
MN323R4BUOtherBLUE CROSS
MNP0057126OtherRAILROAD MEDICARE MN
MN303G7BUOtherBLUE CROSS
WI561350077Medicare PIN
MNG64818Medicare UPIN
MN320216000Medicaid
WI34440000Medicaid
MN1016593OtherPREFERRED ONE
WI040700084Medicare PIN
MN125407OtherUCARE
MN1441752OtherAMERICA'S PPO
MN300003208Medicare PIN
MNHP34848OtherHEALTHPARTNERS
MN300003206Medicare PIN
MN1602644OtherMEDICA
MN300003207Medicare PIN