Provider Demographics
NPI:1629011549
Name:BRUNDAGE, PAUL A (DO)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:BRUNDAGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 CHAMBLISS AVE NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3882
Mailing Address - Country:US
Mailing Address - Phone:423-559-2800
Mailing Address - Fax:423-559-0532
Practice Address - Street 1:2415 CHAMBLISS AVE NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3882
Practice Address - Country:US
Practice Address - Phone:423-559-2800
Practice Address - Fax:423-559-0532
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3945545207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H34310Medicare UPIN
TN3823233Medicare PIN