Basic Information
| Provider Information | |||||||||
| NPI: | 1114932589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUNNER | ||||||||
| FirstName: | NOEMI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 HARVESTER DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605275965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737025957 | ||||||||
| FaxNumber: | 7737020000 | ||||||||
| Practice Location | |||||||||
| Address1: | 5841 S MARYLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7370265277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 41435 TEMP | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 113-000081 | 01 | IL | PHYSICIAN LICENSE | OTHER |