Provider Demographics
NPI:1073062626
Name:BUSH, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2184 BEN COUCH RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-9304
Mailing Address - Country:US
Mailing Address - Phone:912-550-9066
Mailing Address - Fax:
Practice Address - Street 1:2184 BEN COUCH RD
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-9304
Practice Address - Country:US
Practice Address - Phone:912-550-9066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor