Provider Demographics
NPI:1144801408
Name:BUNTING, SAMUEL ROBERT
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ROBERT
Last Name:BUNTING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 HARVESTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-5965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE # MC3077
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-834-0373
Practice Address - Fax:773-702-4297
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361682042084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program