Healthcare Provider Details

I. General information

NPI: 1063859171
Provider Name (Legal Business Name): MICHAEL BRUNT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 07/21/2022
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 350
MARIETTA GA
30060-1129
US

IV. Provider business mailing address

55 WHITCHER ST NE STE 350
MARIETTA GA
30060-1129
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax: 770-528-9938
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-528-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD15308
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number85089
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: