Basic Information
Provider Information | |||||||||
NPI: | 1154383503 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BULLARD | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: | GRAY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | MEDICAL CENTER BLVD | ||||||||
Address2: | WAKE FOREST BAPTIST MEDICAL CENTER | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271570001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367162255 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | MEDICAL CENTER BLVD | ||||||||
Address2: |   | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271570001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367162255 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2006 | ||||||||
LastUpdateDate: | 11/09/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 32654 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | 32654 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
ID | Type | State | Issuer | Description | 2460072/5678036 | 01 |   | AETNA | OTHER | 12338 | 01 |   | PARTNERS | OTHER | 298485 | 01 |   | MAMSI | OTHER | BB0655590 | 01 |   | DEA | OTHER | 890109N | 05 | NC |   | MEDICAID | 19674 | 01 | NC | BCBS | OTHER | 32654 | 01 | NC | NC MEDICAL BOARD | OTHER | 1516879-003 | 01 |   | CIGNA | OTHER | 290005714 | 01 |   | RAILROAD MEDICARE | OTHER | 311001 | 01 |   | COVENTRY | OTHER | 4840048 | 01 |   | UNITED HEALTHCARE | OTHER |