1891853594 NPI number — DR. ANDREW PANCHENKO BUSH MD

Table of content: DR. ANDREW PANCHENKO BUSH MD (NPI 1891853594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891853594 NPI number — DR. ANDREW PANCHENKO BUSH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
ANDREW
Provider Middle Name:
PANCHENKO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1891853594
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANFORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27331-3247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-774-1355
Provider Business Mailing Address Fax Number:
919-775-1644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1139 CARTHAGE STREET
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-774-1355
Provider Business Practice Location Address Fax Number:
919-774-3395
Provider Enumeration Date:
12/05/2006

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: 207X00000X , with the licence number:  9500524 , 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)





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