Basic Information
| Provider Information | |||||||||
| NPI: | 1104818426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNO | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 567 | ||||||||
| Address2: | |||||||||
| City: | CHAGRIN FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440220567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164645160 | ||||||||
| FaxNumber: | 2164645982 | ||||||||
| Practice Location | |||||||||
| Address1: | 29017 CEDAR RD | ||||||||
| Address2: | |||||||||
| City: | LYNDHURST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441244073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404608000 | ||||||||
| FaxNumber: | 4404601759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 67000062 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2256697 | 05 | OH | MEDICAID | 405983 | 01 | OH | WELLCARE MEDICAID | OTHER | POO465328 | 01 | OH | RAILROAD MEDICARE | OTHER | 000000527826 | 01 | OH | ANTHEM | OTHER | 0583328 | 01 | OH | BCMH | OTHER | 0935063 | 01 | OH | AETNA | OTHER | 000000232156 | 01 | OH | UNISON | OTHER |