Basic Information
| Provider Information | |||||||||
| NPI: | 1891762258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUNDY | ||||||||
| FirstName: | MARY LYNN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1919 STATE ST | ||||||||
| Address2: | SUITE 362 | ||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471504929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129445888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1108 NORTHVIEW DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373935781 | ||||||||
| FaxNumber: | 9373935784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 09/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01037496A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 26544 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 35.134104 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 64265440 | 05 | KY | MEDICAID | 200454960A | 05 | IN | MEDICAID | 0297624 | 05 | OH | MEDICAID |