MEDICARE: TIMOTHY WILLIAM BRUNER PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QA01918600	NJ

General Provider Information

NPI Number	:	1063041945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY WILLIAM BRUNER PT, DPT

Provider Business Mailing Address
First Line	:	822 CENTER ST
Second Line	:
City	:	FORKED RIVER
State	:	NJ
Zip	:	08731-1234
Country	:	US
Telephone Number	:	717-599-9033
Fax Number	:

Provider Business Practice Location Address
First Line	:	770 LIGHTHOUSE DR UNIT 170
Second Line	:
City	:	BARNEGAT
State	:	NJ
Zip	:	08005-2373
Country	:	US
Telephone Number	:	609-698-1073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2020
Last Update Date	:	04/03/2020

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