Provider Demographics
NPI:1043391154
Name:BUSH, MARC ALLEN (PA)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:ALLEN
Last Name:BUSH
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:100 MICHIGAN STREET NW
Mailing Address - Street 2:SUITE A721
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-974-4493
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST. NW
Practice Address - Street 2:SUITE A721
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-974-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001779363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP67038Medicare UPIN
MION38550017Medicare ID - Type Unspecified