Provider Demographics
NPI:1891836276
Name:DOUGLAS J. BRUNNER, M. D.
Entity Type:Organization
Organization Name:DOUGLAS J. BRUNNER, M. D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUNNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-595-6521
Mailing Address - Street 1:175 E CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-2212
Mailing Address - Country:US
Mailing Address - Phone:610-595-6521
Mailing Address - Fax:610-595-6077
Practice Address - Street 1:175 E CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-2212
Practice Address - Country:US
Practice Address - Phone:610-595-6542
Practice Address - Fax:610-595-6077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD027564E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0142329000OtherIBC KEYSTONE/PERS CHOICE
PA884151OtherHIGHMARK BLUE SHIELD
PA0009930450002Medicaid
PA0099162OtherAETNA USHC
PADA5481OtherTRAVELERS MEDICARE
PA30018109OtherKEYSTONE MERCY
PADA5481OtherTRAVELERS MEDICARE
PA0099162OtherAETNA USHC