1033532791 NPI number — STEPHEN M. BUSH PA-C

Table of content: STEPHEN M. BUSH PA-C (NPI 1033532791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033532791 NPI number — STEPHEN M. BUSH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
STEPHEN
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:
DIXON
Provider Other First Name:
STEPHEN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1033532791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 FIRSTVILLAGE DRIVE
Provider Second Line Business Mailing Address:
PO BOX 2000
Provider Business Mailing Address City Name:
PINEHURST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-295-6831
Provider Business Mailing Address Fax Number:
910-295-0244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 FIRSTVILLAGE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEHURST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-295-6831
Provider Business Practice Location Address Fax Number:
910-295-0244
Provider Enumeration Date:
01/30/2014

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: 363A00000X , with the licence number:  MB4635465 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0098694 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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