Jeanine L Brunclik, M.D.
Individual provider Active NPI Family Medicine Physician · Saint Croix Falls, WI
NPI 1689758237 · NPPES record last updated Dec 31, 2020
Key facts
- NPI
- 1689758237
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 49004 (WI)
- Practice address
- 235 State St
Saint Croix Falls, WI 54024-4117 - Phone
- (715) 483-3221
- Fax
- (715) 483-0507
- NPI assigned
- Oct 24, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 5
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Family Practice
- Education
- University of Minnesota Medical School, 2003
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- St. Croix Regional Medical Center
Practice addresses (Care Compare)
12375 Lindstrom LN
Lindstrom, MN 55045-9551
Phone (651) 400-2240
235 E State St
Saint Croix Falls, WI 54024-4117
Phone (715) 483-3221
Hospital & facility affiliations
- St Croix Regional Medical Center
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MN, WI
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20060123000245 | MN | Practitioner - Family Practice | 7416971080 | Reassigns benefits to 1 organization |
| I20060417000084 | WI | Practitioner - Family Practice | 7416971080 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 49004 | WI | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| St. Croix Regional Medical Center | Current |
Accepting new patients | |
| St. Croix Regional Medical Center | Current |
Accepting new patients |
Locations
205 Oak St W
Frederic, WI 54837
Phone (715) 327-5700
216 S Adams St
St Croix Fls, WI 54024
Phone (715) 483-0426
235 E State St
St Croix Fls, WI 54024
Phone (715) 483-3221
Interoperability endpoints
- jbrunclik85523@excellian.direct.allina.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 49004 | WI | Yes |
Addresses
Primary practice location
235 State St
Saint Croix Falls, WI 54024-4117
Mailing address
235 State St
Saint Croix Falls, WI 54024-4117
Phone (715) 483-3221
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 389435600 | Medicaid | MN | |
| 080H9BR | Other | MN | BCBS MN PRO FEE |
| 34840300 | Medicaid | WI | |
| 01-23254 | Other | MN | MEDICA |
| NA9031046087 | Other | MN | PREFERRED ONE |
| 501S5BR | Other | MN | BCBS MN FACILITY |
| HP58527 | Other | MN | HEALTHPARTNERS |
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | jbrunclik85523@excellian.direct.allina.com | Direct |
Other providers in Saint Croix Falls, WI
- Breathe and Thrive, LLC
- Tammy Breault
- Shannon M Brice
- Megan Brothen
- Wanda F Brown
- Dana Marie Burcar
- Karly Elizabeth Canney
- Carissa Marie Carlson
- Annette Marie Casey
- Emily Ryan Chapman
All providers in Saint Croix Falls, WI · Family Medicine Physician in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 31, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.