MEDICARE: DR. HAROLD JAY BRUNINGA M.D.

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	207W00000X	Ophthalmology Physician	036073892	IL
2	2083A0100X	Aerospace Medicine Physician	036073892	IL

General Provider Information

NPI Number	:	1912975160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAROLD JAY BRUNINGA M.D.

Provider Business Mailing Address
First Line	:	2125 SOUTHBROOKE RD
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-9201
Country	:	US
Telephone Number	:	217-243-7274
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 CAPITAL AIRPORT DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62707-8410
Country	:	US
Telephone Number	:	217-473-7386
Fax Number	:	217-473-7386

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

Provider Enumeration Date	:	03/12/2006
Last Update Date	:	01/17/2018

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