Healthcare Provider Details

I. General information

NPI: 1952334609
Provider Name (Legal Business Name): EDDY S. BRUNO, M.D., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 W MARKET ST STE 310
LIMA OH
45805-2777
US

IV. Provider business mailing address

PO BOX 217
LIMA OH
45802-0217
US

V. Phone/Fax

Practice location:
  • Phone: 419-225-8808
  • Fax: 419-222-7220
Mailing address:
  • Phone: 419-225-8808
  • Fax: 419-222-7220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35082630
License Number StateOH

VII. Legacy identifiers

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

# 1
Identifier2582709
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name: EDDY SEVERE BRUNO
Title or Position: OWNER
Credential:
Phone: 419-225-8808