Provider Demographics
NPI:1649298225
Name:BRUNNER-BUCK, LORI BETH (MD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:BETH
Last Name:BRUNNER-BUCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:19606 ELK RIDGE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-6438
Mailing Address - Country:US
Mailing Address - Phone:402-658-3014
Mailing Address - Fax:
Practice Address - Street 1:1870 S 75TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-1700
Practice Address - Country:US
Practice Address - Phone:402-575-3500
Practice Address - Fax:402-496-9922
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23344208000000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEI66247Medicare UPIN
NE10026293200Medicaid
NEI66247Medicare UPIN
NE47068731716Medicaid
NE280617Medicare PIN