Provider Demographics
NPI:1093801367
Name:NEW ALBANY SURGICAL GROUP PA
Entity Type:Organization
Organization Name:NEW ALBANY SURGICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:BULLWINKEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-534-8159
Mailing Address - Street 1:226 STARLYN AVE
Mailing Address - Street 2:P.O. BOX 891
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-2428
Mailing Address - Country:US
Mailing Address - Phone:662-534-8159
Mailing Address - Fax:
Practice Address - Street 1:226 STARLYN AVE
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-2428
Practice Address - Country:US
Practice Address - Phone:662-534-8159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS8661208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011230Medicaid
MSC00536Medicare ID - Type UnspecifiedGROUP NUMBER
MS09011230Medicaid