Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | DO0000000839 | TN |
Y | 207N00000X | Dermatologist | DO0000000839 | TN |
N | 208D00000X | General Practice Physician | DO0000000839 | TN |
NPI | 1063425791 |
---|---|
Provider Name | Mr. Forrest K Busch JR. |
First Address | Dyersburg, TN 38024 |
Second Address | Dyersburg, TN 38024 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2006 |
Last Update Date | 10/09/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
070009417 | RAILROAD MEDICARE (01) | TN |
3303355 | (05) | TN |
E34164 | (02) | TN |