Provider Demographics
NPI:1922066695
Name:BRUNS, DALE L (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:L
Last Name:BRUNS
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 1:910 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-2414
Mailing Address - Country:US
Mailing Address - Phone:270-259-1656
Mailing Address - Fax:270-259-9536
Practice Address - Street 1:910 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2414
Practice Address - Country:US
Practice Address - Phone:270-259-1656
Practice Address - Fax:270-259-9536
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30101207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2434820000OtherPASSPORT ADVANTAGE
KY64301013Medicaid
KY1069832OtherPASSPORT HEALTH PLAN
KY1069832OtherPASSPORT
KY64301013Medicaid
KY3317859Medicare PIN