Individual
MARK THOMAS BRULTE
Active
Individual
MARK THOMAS BRULTE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
048490
GA
207R00000X
Internal Medicine Physician
Primary
048490
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000873441H
—
GA
05
—
000873441I
—
GA
05
—
0008734441F
—
GA
05
—
00873441A
—
GA
01
—
128214
PEACHSTATE
GA
01
—
478042
WELLCARE-DOUGLAS
GA
01
—
541189
WELLCARE-WILLACOOCHEE
GA
01
—
543782
WELLCARE-NICHOLLS
GA
01
—
GRP7301
MEDICARE GROUP #
GA
Enumeration date
09/13/2006
Last updated
12/08/2010
Update your record
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