Basic Information
| Provider Information | |||||||||
| NPI: | 1235195264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUNT | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032553417 | ||||||||
| FaxNumber: | 8032553451 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032562657 | ||||||||
| FaxNumber: | 8032553451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 9984 | SC | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 9984 | SC | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 099841 | 05 | SC | MEDICAID |