Healthcare Provider Details

I. General information

NPI: 1891053492
Provider Name (Legal Business Name): NICHOLAS EDWARD BRUNS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 09/25/2025
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-446-3350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021-01383
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number2021-01383
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2021-01383
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: