1285684803 NPI number — TINA C BUNCH MD

Table of content: TINA C BUNCH MD (NPI 1285684803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285684803 NPI number — TINA C BUNCH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUNCH
Provider First Name:
TINA
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285684803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26726
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78755-0726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-407-8686
Provider Business Mailing Address Fax Number:
512-421-4489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6811 AUSTIN CENTER BLVD.
Provider Second Line Business Practice Location Address:
#300
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78731-3166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-346-8888
Provider Business Practice Location Address Fax Number:
512-344-0365
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  M1572 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: M1572 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 194010802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 194010801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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