Healthcare Provider Details

I. General information

NPI: 1093801367
Provider Name (Legal Business Name): NEW ALBANY SURGICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 STARLYN AVE
NEW ALBANY MS
38652-2428
US

IV. Provider business mailing address

226 STARLYN AVE P.O. BOX 891
NEW ALBANY MS
38652-2428
US

V. Phone/Fax

Practice location:
  • Phone: 662-534-8159
  • Fax:
Mailing address:
  • Phone: 662-534-8159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number8661
License Number StateMS

VIII. Authorized Official

Name: BRUCE ALLAN BULLWINKEL
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 662-534-8159