1730168030 NPI number — VALERIE L BUSH PAC

Table of content: VALERIE L BUSH PAC (NPI 1730168030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730168030 NPI number — VALERIE L BUSH PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
VALERIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

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:
1730168030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 MIMOSA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOMASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31792-6605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-551-0083
Provider Business Mailing Address Fax Number:
229-227-9642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 MIMOSA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THOMASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31792-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-551-0083
Provider Business Practice Location Address Fax Number:
229-227-9642
Provider Enumeration Date:
01/13/2006

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: 363AM0700X , with the licence number:  3598 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100000112B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100000112A . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 368501 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 970017094 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 100000112A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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