Basic Information
| Provider Information | |||||||||
| NPI: | 1427083963 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRYAN E BRUNS MD A MEDICAL CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 511278 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900517833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662842771 | ||||||||
| FaxNumber: | 8003341041 | ||||||||
| Practice Location | |||||||||
| Address1: | 9255 TOWNE CENTRE DR | ||||||||
| Address2: | SUITE 370 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921213033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585350091 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 01/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | BRUNS | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8585350091 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | G29642 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00G296420 | 05 | CA | MEDICAID |