Healthcare Provider Details

I. General information

NPI: 1114946738
Provider Name (Legal Business Name): MARISSA A BRUNETTI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

IV. Provider business mailing address

100 E PENN SQ THE WANAMAKER BUILDING, 9TH FLOOR, NORTH
PHILADELPHIA PA
19107-3323
US

V. Phone/Fax

Practice location:
  • Phone: 800-243-1455
  • Fax:
Mailing address:
  • Phone: 267-425-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD63275
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD439981
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier1026270630001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
IdentifierKJ50GB/64687801
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerCAREFIRST MARYLAND GBMC
# 3
IdentifierS1390049
Identifier TypeOTHER
Identifier StateMD
Identifier IssuerCAREFIRST REGIONAL GBMC
# 4
Identifier409240600
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer
# 5
Identifier226140EMD
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: