Healthcare Provider Details

I. General information

NPI: 1598784621
Provider Name (Legal Business Name): PETER ANDREW BUNDGARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DR WALTHALL COUNTY GENERAL HOSPITAL
TYLERTOWN MS
39667-2022
US

IV. Provider business mailing address

PO BOX 940
WASHINGTON MS
39190-0940
US

V. Phone/Fax

Practice location:
  • Phone: 601-876-2122
  • Fax:
Mailing address:
  • Phone: 601-446-6899
  • Fax: 601-304-9714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15002
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: