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General NPI Number Information
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NPI Number | 1164725271
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Entity Type | Individual
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Provider Name | ELIZABETH BARRETT BRUNNER PA
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Gender | Female
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Dates
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Enumeration Date | 12/10/2010
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Last Update Date | 12/10/2010
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Provider Practice Location Address
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Address Line | 6071 W OUTER DR
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City | DETROIT
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State | MI
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Zip | 48235-2624
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Country | US
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Telephone | 313-966-6896
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Fax |
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Provider Business Mailing Address
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Address Line | 1102 MIDLAND BLVD
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City | ROYAL OAK
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State | MI
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Zip | 48073-2889
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Country | US
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Telephone | 248-515-0576
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5601005847
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License Number State | MI
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