Healthcare Provider Details

I. General information

NPI: 1083685440
Provider Name (Legal Business Name): CHARLES W BRUNELLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 N EASTOWN RD
LIMA OH
45807-2214
US

IV. Provider business mailing address

81 HAWTHORNE DR
LIMA OH
45805-4074
US

V. Phone/Fax

Practice location:
  • Phone: 419-228-3500
  • Fax: 419-228-6700
Mailing address:
  • Phone: 419-999-1312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35042012
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0361335
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: