Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 2000158294 | MO |
Y | 208600000X | Surgeon | 2000158294 | MO |
NPI | 1023002573 |
---|---|
Provider Name | Stephen Michael Bush |
First Address | Atlanta, GA 30384-5454 |
Second Address | Kennett, MO 63857-3248 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2005 |
Last Update Date | 23/07/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
205015506 | (05) | MO |
G02568 | (02) | MO |