Basic Information
Provider Information | |||||||||
NPI: | 1356354187 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUSH | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | KEITH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M..D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2379 | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | KY | ||||||||
PostalCode: | 411052379 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6063244745 | ||||||||
FaxNumber: | 6063244941 | ||||||||
Practice Location | |||||||||
Address1: | 613 23RD ST. SUITE 230 | ||||||||
Address2: | MEDICAL PLAZA B | ||||||||
City: | ASHLAND | ||||||||
State: | KY | ||||||||
PostalCode: | 41101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6063244745 | ||||||||
FaxNumber: | 6063244941 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2006 | ||||||||
LastUpdateDate: | 11/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 26723 | KY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 642672 | 05 | KY |   | MEDICAID | 64267230 | 05 | KY |   | MEDICAID | 0086359000 | 05 | WV |   | MEDICAID | 0976261 | 05 | OH |   | MEDICAID |