Provider Demographics
NPI:1093719874
Name:BUSH, OMALLAH (AUD)
Entity Type:Individual
Prefix:
First Name:OMALLAH
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD STE 300N
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5703
Mailing Address - Country:US
Mailing Address - Phone:281-286-2999
Mailing Address - Fax:512-607-4893
Practice Address - Street 1:1360 W STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-3613
Practice Address - Country:US
Practice Address - Phone:330-821-2012
Practice Address - Fax:330-823-4799
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA-01176231H00000X
OH237700000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4287171OtherMEDICARE