Provider Demographics
NPI:1164418182
Name:BRADENTON SURGICAL GROUP PA
Entity Type:Organization
Organization Name:BRADENTON SURGICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BUNCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-744-2700
Mailing Address - Street 1:200 3RD AVE W
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8626
Mailing Address - Country:US
Mailing Address - Phone:941-744-2700
Mailing Address - Fax:941-744-2705
Practice Address - Street 1:200 3RD AVE W
Practice Address - Street 2:STE 110
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8626
Practice Address - Country:US
Practice Address - Phone:941-744-2700
Practice Address - Fax:941-744-2705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCK2566OtherRAIL ROAD MEDICARE
FL7385373OtherAETNA
FL94850OtherBCBS
FL94850Medicare PIN