Provider Demographics
NPI:1023016391
Name:BYNUM, GUS A (MD)
Entity Type:Individual
Prefix:DR
First Name:GUS
Middle Name:A
Last Name:BYNUM
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 1:1154A LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9330
Mailing Address - Country:US
Mailing Address - Phone:502-868-0008
Mailing Address - Fax:
Practice Address - Street 1:1154A LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9330
Practice Address - Country:US
Practice Address - Phone:502-868-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000049706OtherANTHEM
KY64169360Medicaid
000000049706OtherANTHEM
C73186Medicare UPIN