MEDICARE: DALE L. BRUNS MD

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	207P00000X	Emergency Medicine Physician	30101	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2434820000	OTHER	KY	PASSPORT ADVANTAGE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1069832	OTHER	KY	PASSPORT HEALTH PLAN
4	1069832	OTHER	KY	PASSPORT

General Provider Information

NPI Number	:	1922066695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE L. BRUNS MD

Provider Business Mailing Address
First Line	:	910 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-2414
Country	:	US
Telephone Number	:	270-259-1656
Fax Number	:	270-259-9536

Provider Business Practice Location Address
First Line	:	910 WALLACE AVE
Second Line	:
City	:	LEITCHFIELD
State	:	KY
Zip	:	42754-2414
Country	:	US
Telephone Number	:	270-259-1656
Fax Number	:	270-259-9536

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	10/23/2008

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Directions to “ DALE L. BRUNS MD” Practice Location

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