Healthcare Provider Details

I. General information

NPI: 1114832730
Provider Name (Legal Business Name): ANDREW BUSH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W 20TH ST
LAUREL MS
39440-1802
US

IV. Provider business mailing address

1707 W 20TH ST
LAUREL MS
39440-1802
US

V. Phone/Fax

Practice location:
  • Phone: 601-428-2004
  • Fax: 601-428-8833
Mailing address:
  • Phone: 601-428-2004
  • Fax: 601-428-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8276
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: