Healthcare Provider Details

I. General information

NPI: 1215166319
Provider Name (Legal Business Name): MICHAEL BRUNNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 W STEARNS RD
BARTLETT IL
60103-4509
US

IV. Provider business mailing address

1515 E LAKE ST ATTN: ABMG PRIMARY CARE
HANOVER PARK IL
60133-4869
US

V. Phone/Fax

Practice location:
  • Phone: 630-716-7500
  • Fax:
Mailing address:
  • Phone: 630-483-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.133928
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125055948
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: