Basic Information
| Provider Information | |||||||||
| NPI: | 1982807392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNNING | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3714 GUARDIAN AVE | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285572974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2222472101 | ||||||||
| FaxNumber: | 2522474675 | ||||||||
| Practice Location | |||||||||
| Address1: | 3714 GUARDIAN AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285572974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522472101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | OS9814 | FL | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | 2011-01863 | NC | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 94655 | 01 | FL | BCBS | OTHER | 279031900 | 05 | FL | MEDICAID | 117472 | 01 | FL | OPERATING ENGINEERS | OTHER | 344465 | 01 | FL | AVMED | OTHER | P00468955 | 01 | FL | RAILROAD MEDICARE | OTHER | 7137932 | 01 | FL | AETNA PROVIDER # | OTHER |