Healthcare Provider Details

I. General information

NPI: 1457382764
Provider Name (Legal Business Name): GERARD S BRUNGARDT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8533 E 32ND ST N
WICHITA KS
67226-2611
US

IV. Provider business mailing address

PO BOX 1358
WICHITA KS
67201-1358
US

V. Phone/Fax

Practice location:
  • Phone: 316-293-2622
  • Fax: 855-517-9494
Mailing address:
  • Phone: 316-293-3429
  • Fax: 316-293-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number04-20542
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number04-20542
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number04-20542
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: