Provider Demographics
NPI:1033119375
Name:BUSH, MARY ANN (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:BUSH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 MARTIN ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4933
Mailing Address - Country:US
Mailing Address - Phone:336-724-1333
Mailing Address - Fax:336-724-1166
Practice Address - Street 1:1520 MARTIN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4933
Practice Address - Country:US
Practice Address - Phone:336-724-1333
Practice Address - Fax:336-724-1166
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
NC4451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2504984Medicare ID - Type UnspecifiedPHYSICAL THERAPIST