1932607546 NPI number — MR. PERNELL M.J BUSH LCSW

Table of content: MR. PERNELL M.J BUSH LCSW (NPI 1932607546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932607546 NPI number — MR. PERNELL M.J BUSH LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
PERNELL
Provider Middle Name:
M.J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUSH
Provider Other First Name:
PERNELL
Provider Other Middle Name:
MICHEALJEREMY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1932607546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
819 E 1ST ST STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANFORD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32771-1467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-906-0139
Provider Business Mailing Address Fax Number:
407-542-5935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
819 E 1ST ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32771-1467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-906-0139
Provider Business Practice Location Address Fax Number:
407-542-5935
Provider Enumeration Date:
01/29/2018

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: 1041C0700X , with the licence number:  SW18109 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: WMRMF . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5845848 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6157870 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 601535783 . This is a "MEGELLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: OH308 . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1099907 . This is a "OPTUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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