Healthcare Provider Details

I. General information

NPI: 1053373563
Provider Name (Legal Business Name): JERRY A BUSHEY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CENTER ST
ST JOHNSVILLE NY
13452-1127
US

IV. Provider business mailing address

30 CENTER ST
ST JOHNSVILLE NY
13452-1127
US

V. Phone/Fax

Practice location:
  • Phone: 518-568-0032
  • Fax: 518-568-0035
Mailing address:
  • Phone: 518-568-0032
  • Fax: 518-568-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number015232-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: