Basic Information
| Provider Information | |||||||||
| NPI: | 1912934191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUNE | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435243378 | ||||||||
| FaxNumber: | 8435248179 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435243378 | ||||||||
| FaxNumber: | 8435241879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 12/10/2007 | ||||||||
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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 | 2084P0800X | 029597 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00401596A | 05 | GA | MEDICAID | G29597 | 01 | SC | SOUTH CAROLINA MEDICAID | OTHER |