Basic Information
| Provider Information | |||||||||
| NPI: | 1750812285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNTEN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BILLQUIST | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | JOY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 718 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PALMYRA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634611923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304147050 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | ML 2001 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364408 | ||||||||
| FaxNumber: | 5136367337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2017 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207LP3000X | 35.146573 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
No ID Information.