1699066001 NPI number — ADAM BUNTAINE MD

Table of content: ADAM BUNTAINE MD (NPI 1699066001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699066001 NPI number — ADAM BUNTAINE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUNTAINE
Provider First Name:
ADAM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1699066001
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
795 GOLF VISTA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30004-3030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-747-7420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3970 DEPUTY BILL CANTRELL MEMORIAL RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-513-2273
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2011

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:  2017-00074 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 80200 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 80200 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X , with the licence number: 172809 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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