Basic Information
| Provider Information | |||||||||
| NPI: | 1588642169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUNCH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | HOLT | ||||||||
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| Credential: | M.D., F.A.C.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 402145 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967306 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 LAUREL ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032563400 | ||||||||
| FaxNumber: | 8032562039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 7906 | SC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 079060 | 05 | SC | MEDICAID |