MEDICARE: DR. DAVID T BUSCH PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1377	GA

General Provider Information

NPI Number	:	1053343699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID T BUSCH PH.D.

Provider Business Mailing Address
First Line	:	740 LITTLE ROCK CREEK RD
Second Line	:
City	:	CHERRYLOG
State	:	GA
Zip	:	30522-2904
Country	:	US
Telephone Number	:	706-635-8200
Fax Number	:	706-635-8201

Provider Business Practice Location Address
First Line	:	740 LITTLE ROCK CREEK RD
Second Line	:
City	:	CHERRYLOG
State	:	GA
Zip	:	30522-2904
Country	:	US
Telephone Number	:	706-635-8200
Fax Number	:	706-635-8201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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