Provider Demographics
NPI:1255312278
Name:BUSH, JOEL G (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:G
Last Name:BUSH
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:PO BOX 3799
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3799
Mailing Address - Country:US
Mailing Address - Phone:931-245-8300
Mailing Address - Fax:931-245-8360
Practice Address - Street 1:2147 WILMA RUDOLPH BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6663
Practice Address - Country:US
Practice Address - Phone:931-245-8300
Practice Address - Fax:931-245-8360
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7520207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3156881Medicaid
B02651Medicare UPIN
TN3156881Medicaid