Healthcare Provider Details

I. General information

NPI: 1679397210
Provider Name (Legal Business Name): COURTLAND MCCOLLUM BUNTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 W 3RD AVE
ALBANY GA
31701-1943
US

IV. Provider business mailing address

417 W 3RD AVE
ALBANY GA
31701-1943
US

V. Phone/Fax

Practice location:
  • Phone: 229-312-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number12696
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: