Healthcare Provider Details

I. General information

NPI: 1720546203
Provider Name (Legal Business Name): BRENDON AUGUSTINE BAMBIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-1000
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5000
  • Fax:
Mailing address:
  • Phone: 208-830-7712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberR3880
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: