Provider Demographics
NPI:1053314070
Name:BOUSH, GEORGE ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:ANDREW
Last Name:BOUSH
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 1:123 HOSPITAL DR
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3331
Mailing Address - Country:US
Mailing Address - Phone:920-261-8225
Mailing Address - Fax:920-261-5343
Practice Address - Street 1:123 HOSPITAL DR
Practice Address - Street 2:SUITE 1002
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3331
Practice Address - Country:US
Practice Address - Phone:920-261-8225
Practice Address - Fax:920-261-5343
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31275-020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31675900Medicaid
WI31675900Medicaid
WI135607Medicare ID - Type Unspecified