=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255465043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUNI PEDIATRIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9454 THREE RIVERS RD SUITE A
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-4294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-864-7747
-----------------------------------------------------
Fax | 228-864-7415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9454 THREE RIVERS RD SUITE A
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-4294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-864-7747
-----------------------------------------------------
Fax | 228-864-7415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TIM G. BRUNI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 228-864-7747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------