Healthcare Provider Details

I. General information

NPI: 1174950661
Provider Name (Legal Business Name): JACK MICHAEL BRUNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 N RANDALL RD
ELGIN IL
60123-2300
US

IV. Provider business mailing address

6552 N OXFORD AVE
CHICAGO IL
60631-1529
US

V. Phone/Fax

Practice location:
  • Phone: 847-742-9800
  • Fax:
Mailing address:
  • Phone: 941-321-9790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004840
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002688A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number853623
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085004840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: