1629248406 NPI number — KELLY A BUSHUR CP PH.D

Table of content: KELLY A BUSHUR CP PH.D (NPI 1629248406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629248406 NPI number — KELLY A BUSHUR CP PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSHUR
Provider First Name:
KELLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CP PH.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RHODES
Provider Other First Name:
KELLY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CP PH.D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629248406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62918-0577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-985-8221
Provider Business Mailing Address Fax Number:
618-985-6860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S LEWIS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARBONDALE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62901-3547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-519-9900
Provider Business Practice Location Address Fax Number:
618-529-1384
Provider Enumeration Date:
03/07/2008

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: 103TC0700X , with the licence number:  071005772 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 370966854006 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 370966854015 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 370966854002 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 370966854024 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 370966854005 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640701 . This is a "MEDICARE GROUP ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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