Healthcare Provider Details

I. General information

NPI: 1740281310
Provider Name (Legal Business Name): STEPHEN BRUNNQUELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 ELM ST
HARRINGTON PARK NJ
07640-1902
US

IV. Provider business mailing address

24 ELM ST
HARRINGTON PARK NJ
07640-1902
US

V. Phone/Fax

Practice location:
  • Phone: 201-784-0123
  • Fax: 201-784-0065
Mailing address:
  • Phone: 201-784-0123
  • Fax: 201-784-0065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA05743400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: