Healthcare Provider Details

I. General information

NPI: 1427077908
Provider Name (Legal Business Name): JEFFREY LANE BUSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 DANTIGNAC ST STE 1000
AUGUSTA GA
30901-2776
US

IV. Provider business mailing address

3696 WHEELER RD
AUGUSTA GA
30909-6520
US

V. Phone/Fax

Practice location:
  • Phone: 68-212-9447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number051300
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: