Provider Demographics
NPI:1881601953
Name:BRUNK, SUSAN (CNM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BRUNK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WALNUT ST
Mailing Address - Street 2:14TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-829-8000
Mailing Address - Fax:215-829-8623
Practice Address - Street 1:800 WALNUT ST
Practice Address - Street 2:14TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-829-8000
Practice Address - Fax:215-829-8623
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008586L367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013209500001Medicaid
PA0013209500001Medicaid
PA214464Medicare PIN