1982680047 NPI number — SHIRLEY BUSCH

Table of content: SHIRLEY BUSCH (NPI 1982680047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982680047 NPI number — SHIRLEY BUSCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSCH
Provider First Name:
SHIRLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1982680047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3421 CONCORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17402-9001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-851-1405
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 MONUMENT RD STE 270
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17403-5073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-741-8250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2005

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: 367500000X , with the licence number:  RN243038L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101677196 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".