Basic Information
| Provider Information | |||||||||
| NPI: | 1760413249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUDNYK | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325412909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506507606 | ||||||||
| FaxNumber: | 8503371698 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325412909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506507606 | ||||||||
| FaxNumber: | 8503371698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME61503 | FL | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 207L00000X | ME61503 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 376054500 | 05 | FL | MEDICAID | 25454 | 01 | FL | BCBS | OTHER |