Healthcare Provider Details

I. General information

NPI: 1336182633
Provider Name (Legal Business Name): GREGORY A. BAMBACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7870W US HIGHWAY 2
MANISTIQUE MI
49854-8992
US

IV. Provider business mailing address

7870W US HIGHWAY 2
MANISTIQUE MI
49854-8992
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-2143
  • Fax: 906-341-3299
Mailing address:
  • Phone: 906-341-2143
  • Fax: 906-341-3299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number39912
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberGB059652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: