Healthcare Provider Details

I. General information

NPI: 1013044700
Provider Name (Legal Business Name): ANN BENNETT BRUNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MOUNTAIN MANOR TREATMENT CENTER 3800 FREDERICK AVENUE
BALTIMORE MD
21229
US

IV. Provider business mailing address

902 FALLSCROFT WAY
LUTHERVILLE MD
21093-1705
US

V. Phone/Fax

Practice location:
  • Phone: 410-233-1400
  • Fax:
Mailing address:
  • Phone: 410-308-3179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD41505
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD31948
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberD41505
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMD31948
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: