Provider Demographics
NPI:1053381590
Name:BRUNDAGE, RANDALL GEORGE (DO)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:GEORGE
Last Name:BRUNDAGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PECKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2242
Mailing Address - Country:US
Mailing Address - Phone:570-489-0871
Mailing Address - Fax:570-489-8021
Practice Address - Street 1:320 KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:PECKVILLE
Practice Address - State:PA
Practice Address - Zip Code:18452-2242
Practice Address - Country:US
Practice Address - Phone:570-489-0871
Practice Address - Fax:570-489-8021
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05005830L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001162200Medicaid
PA034324Medicare PIN
E13504Medicare UPIN