Healthcare Provider Details

I. General information

NPI: 1891762258
Provider Name (Legal Business Name): MARY LYNN BUNDY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 NORTHVIEW DR STE 1
HILLSBORO OH
45133
US

IV. Provider business mailing address

1919 STATE ST SUITE 362
NEW ALBANY IN
47150-4929
US

V. Phone/Fax

Practice location:
  • Phone: 937-393-5781
  • Fax: 937-393-5784
Mailing address:
  • Phone: 812-944-5888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01037496A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number26544
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.134104
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: