Provider Demographics
NPI:1225215015
Name:GEOFFREY BUNCKE MD PC
Entity Type:Organization
Organization Name:GEOFFREY BUNCKE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHARISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-973-5000
Mailing Address - Street 1:1040 NW 22ND
Mailing Address - Street 2:SUITE 550
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-973-5000
Mailing Address - Fax:503-274-0188
Practice Address - Street 1:1040 NW 22ND
Practice Address - Street 2:SUITE 550
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-973-5000
Practice Address - Fax:503-274-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD238062082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE39901Medicare UPIN
ORR140492Medicare PIN