Provider Demographics
NPI:1588642169
Name:BUNCH, ROBERT HOLT (MD, FACS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HOLT
Last Name:BUNCH
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7306
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1850 LAUREL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2627
Practice Address - Country:US
Practice Address - Phone:803-256-3400
Practice Address - Fax:803-256-2039
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7906208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC079060Medicaid
SCC609855925Medicare PIN
SCC60985Medicare UPIN
SCC609851287Medicare ID - Type Unspecified