Provider Demographics
NPI:1851323000
Name:BRUTKIEWICZ, ROBERT CARL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CARL
Last Name:BRUTKIEWICZ
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:PO BOX 850489
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-0489
Mailing Address - Country:US
Mailing Address - Phone:251-342-3949
Mailing Address - Fax:251-631-3361
Practice Address - Street 1:6345 AIRPORT BLVD STE S
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3127
Practice Address - Country:US
Practice Address - Phone:251-344-1515
Practice Address - Fax:251-344-1455
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000008869Medicaid
AL051508869OtherBLUE CROSS BLUE SHIELD OF ALABAMA
000008869Medicare ID - Type Unspecified
AL000008869Medicaid