Provider Demographics
NPI:1275666844
Name:BUNCH, EDWIN LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:LEWIS
Last Name:BUNCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-3715
Mailing Address - Country:US
Mailing Address - Phone:859-255-8422
Mailing Address - Fax:859-255-0387
Practice Address - Street 1:660 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-3715
Practice Address - Country:US
Practice Address - Phone:859-255-8422
Practice Address - Fax:859-255-0387
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18113174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64181134Medicaid
KYC71294Medicare UPIN
KY64181134Medicaid