Provider Demographics
NPI:1144391202
Name:BRUNNER, MICHAEL MATTHEW (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:MATTHEW
Last Name:BRUNNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 JEANETTE RD
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3828
Mailing Address - Country:US
Mailing Address - Phone:607-785-0907
Mailing Address - Fax:
Practice Address - Street 1:120 PLAZA DR
Practice Address - Street 2:SUITE E
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3640
Practice Address - Country:US
Practice Address - Phone:607-797-5414
Practice Address - Fax:607-797-6537
Is Sole Proprietor?:No
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011764-1225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000089686OtherGHI-HMO
NY02252115Medicaid
NY4552539OtherAETNA-EPO
NY438126OtherMVP
NY4552539OtherAETNA
NY10055823OtherCDPHP
NY64-01196OtherUHC-PPO
NY9976077625901OtherGEICO
NYG0186259040OtherMONROE
NY3962334OtherAETNA-HMO
NY6697062OtherGHI-PPO
NY9976077625901OtherGEICO