Provider Demographics
NPI:1174537914
Name:BRUNK, GLEN A (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:A
Last Name:BRUNK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1049
Mailing Address - Country:US
Mailing Address - Phone:317-859-7222
Mailing Address - Fax:317-859-4268
Practice Address - Street 1:679 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1049
Practice Address - Country:US
Practice Address - Phone:317-859-7222
Practice Address - Fax:317-859-7220
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026203A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100194370OtherMEDICAID GROUP NUMBER
IN340012486OtherMEDICARE RAILROAD
IN000000091688OtherANTHEM PROVIDER NUMBER
IN340012514OtherMEDICARE RAILROAD
1487680518OtherGROUP NPI #
IN100352480Medicaid
IN340012500OtherMEDICARE RAILROAD
IN100352480Medicaid
IN340012486OtherMEDICARE RAILROAD
IN677730BMedicare PIN
IN100194370OtherMEDICAID GROUP NUMBER
1487680518OtherGROUP NPI #