Provider Demographics
NPI:1336182633
Name:BAMBACH, GREGORY A (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:BAMBACH
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 1:7870W US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-8992
Mailing Address - Country:US
Mailing Address - Phone:906-341-2143
Mailing Address - Fax:906-341-3299
Practice Address - Street 1:7870W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-8992
Practice Address - Country:US
Practice Address - Phone:906-341-2143
Practice Address - Fax:906-341-3299
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39912208600000X
MIGB059652208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4992780Medicaid
MN812880500Medicaid
G51724Medicare UPIN
MN812880500Medicaid
MI4992780Medicaid