Healthcare Provider Details

I. General information

NPI: 1093740920
Provider Name (Legal Business Name): GEORGE R BUSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 S 13TH AVENUE
LAUREL MS
39440
US

IV. Provider business mailing address

307 S 13TH AVENUE
LAUREL MS
39440
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-7600
  • Fax: 601-649-7628
Mailing address:
  • Phone: 601-649-7600
  • Fax: 601-649-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7631
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: