Provider Demographics
NPI:1023002573
Name:BUSH, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:BUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 405454
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5454
Mailing Address - Country:US
Mailing Address - Phone:573-888-0555
Mailing Address - Fax:573-888-0556
Practice Address - Street 1:509 SOUTH BYP
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3248
Practice Address - Country:US
Practice Address - Phone:573-888-0555
Practice Address - Fax:573-888-0556
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000158294208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205015506Medicaid
MO000015370Medicare PIN
MO000094853Medicare ID - Type Unspecified
MO205015506Medicaid