1518290345 NPI number — MICHAEL M. BUSH PA-C

Table of content: ANDREW NIENHUIS (NPI 1588415830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518290345 NPI number — MICHAEL M. BUSH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
MICHAEL
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518290345
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 JOHN ST
Provider Second Line Business Mailing Address:
SUITE M283
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49007-5341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-349-7696
Provider Business Mailing Address Fax Number:
269-488-8313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 JOHN ST
Provider Second Line Business Practice Location Address:
SUITE M283
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49007-5341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-349-7696
Provider Business Practice Location Address Fax Number:
269-488-8313
Provider Enumeration Date:
09/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  5601005629 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5390078 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5601005629 . This is a "PHYSICIAN ASSISTANT LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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