Healthcare Provider Details

I. General information

NPI: 1053386060
Provider Name (Legal Business Name): MARK I. BRUNNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S 2ND ST
DANVILLE KY
40422-1804
US

IV. Provider business mailing address

4071 TATES CREEK CENTRE DR STE 202
LEXINGTON KY
40517-3094
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-5302
  • Fax: 859-236-5025
Mailing address:
  • Phone: 859-971-4695
  • Fax: 859-971-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number40350
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: