Provider Demographics
NPI:1801814066
Name:BRUMMEL, ERIC DALE (PT)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:DALE
Last Name:BRUMMEL
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:PO BOX 13159
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-3159
Mailing Address - Country:US
Mailing Address - Phone:928-445-5639
Mailing Address - Fax:928-442-0031
Practice Address - Street 1:115 E GOODWIN ST
Practice Address - Street 2:SUITE E1
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-3926
Practice Address - Country:US
Practice Address - Phone:928-445-5639
Practice Address - Fax:928-442-0031
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3833225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ554239Medicaid
AZAZ0463420OtherBCBS
AZ65039Medicare ID - Type UnspecifiedPRESCOTT
AZAZ0463420OtherBCBS