Basic Information
| Provider Information | |||||||||
| NPI: | 1255457693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNCHER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | W | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1124 SAM RITTENBERG BLVD | ||||||||
| Address2: | STE 1 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294073362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435563462 | ||||||||
| FaxNumber: | 8437662103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1124 SAM RITTENBERG BLVD | ||||||||
| Address2: | STE 1 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294073362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435563462 | ||||||||
| FaxNumber: | 8437662103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 15523 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP1103 | 05 | SC | MEDICAID | TL6124 | 05 | SC | MEDICAID |