Basic Information
| Provider Information | |||||||||
| NPI: | 1477577500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUNDAGE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 BERRYWOOD DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734498771 | ||||||||
| FaxNumber: | 5734496563 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 DIAMOND RDG STE 800 | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651097906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737619360 | ||||||||
| FaxNumber: | 5737619362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 106726 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.