Provider Demographics
NPI:1023161809
Name:BRUNNER, RICHARD G (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:BRUNNER
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 1:4250 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-1917
Mailing Address - Country:US
Mailing Address - Phone:850-526-2200
Mailing Address - Fax:
Practice Address - Street 1:4896A HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-7840
Practice Address - Country:US
Practice Address - Phone:850-526-6700
Practice Address - Fax:850-526-6701
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0046858207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02676OtherBLUE CROSS BLUE SHIELD
FL035342601Medicaid
D50601Medicare UPIN
FL02676YMedicare ID - Type Unspecified