=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114951563
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFF W BUSH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 01/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 EAST BROAD STREET STE A
-----------------------------------------------------
City | EUFAULA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-687-3836
-----------------------------------------------------
Fax | 334-687-0725
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 E. BROAD ST. STE A
-----------------------------------------------------
City | EUFAULA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-687-3836
-----------------------------------------------------
Fax | 334-687-0725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 19771
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------