Provider Demographics
NPI:1922058775
Name:BRUNDAGE, TIMOTHY N (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:N
Last Name:BRUNDAGE
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 1:6500 38TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1629
Mailing Address - Country:US
Mailing Address - Phone:727-344-4795
Mailing Address - Fax:727-344-4712
Practice Address - Street 1:6500 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1629
Practice Address - Country:US
Practice Address - Phone:727-344-4795
Practice Address - Fax:727-344-4712
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 88586207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2704552-00Medicaid
FL44144OtherBCBS
FLI15199Medicare UPIN
FL44144AMedicare PIN