Basic Information
| Provider Information | |||||||||
| NPI: | 1487004230 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUNN | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | JASON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 HOUGHTON AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895836800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEADOWS PKWY | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125355555 | ||||||||
| FaxNumber: | 9125355891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2016 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301110110 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 82620 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.