Healthcare Provider Details

I. General information

NPI: 1760060800
Provider Name (Legal Business Name): MICHAEL ROBERT BRUNNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 N 3RD AVE
PHOENIX AZ
85013-4434
US

IV. Provider business mailing address

8070 ELLIS RD
BARTLETT TN
38133-2806
US

V. Phone/Fax

Practice location:
  • Phone: 844-324-6684
  • Fax:
Mailing address:
  • Phone: 810-305-2825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number80554
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: