Basic Information
| Provider Information | |||||||||
| NPI: | 1710981469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUNER | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 FOXRIDGE DR | ||||||||
| Address2: | STE 240 | ||||||||
| City: | MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662022338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132613153 | ||||||||
| FaxNumber: | 9132623295 | ||||||||
| Practice Location | |||||||||
| Address1: | 5800 FOXRIDGE DR | ||||||||
| Address2: | STE 240 | ||||||||
| City: | MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662022338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132613153 | ||||||||
| FaxNumber: | 9132623295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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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 | 2085R0202X | 04-27631 | KS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2000172082 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100381650B | 05 | KS | MEDICAID | 100381650A | 05 | KS | MEDICAID | 205166101 | 05 | MO | MEDICAID |