Provider Demographics
NPI:1104818426
Name:BRUNO, REGINA M (AA)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:M
Last Name:BRUNO
Suffix:
Gender:F
Credentials:AA
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 567
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-0567
Mailing Address - Country:US
Mailing Address - Phone:216-464-5160
Mailing Address - Fax:216-464-5982
Practice Address - Street 1:29017 CEDAR RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-4073
Practice Address - Country:US
Practice Address - Phone:440-460-8000
Practice Address - Fax:440-460-1759
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67000062367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2256697Medicaid
OH405983OtherWELLCARE MEDICAID
OHPOO465328OtherRAILROAD MEDICARE
OH000000527826OtherANTHEM
OH0583328OtherBCMH
OH0935063OtherAETNA
OH000000232156OtherUNISON
OH0583328OtherBCMH
OHBR8228293Medicare PIN