MEDICARE: MARY R BRUNNER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	01040340	IN
2	208000000X	Pediatrics Physician	01040340A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871535567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY R BRUNNER M.D.

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 W OAK ST
Second Line	:	SUITE 210
City	:	ZIONSVILLE
State	:	IN
Zip	:	46077-3836
Country	:	US
Telephone Number	:	317-873-8855
Fax Number	:	317-873-8853

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	08/30/2022

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