Provider Demographics
NPI:1285672055
Name:BUSH, THOMAS (PSYD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CRANES ROOST CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3650
Mailing Address - Country:US
Mailing Address - Phone:270-765-2605
Mailing Address - Fax:
Practice Address - Street 1:1311 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2621
Practice Address - Country:US
Practice Address - Phone:270-765-2605
Practice Address - Fax:270-766-1222
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid
KY341172OtherTRICARE
11574907OtherCAQH
KY000000044420OtherANTHEM
R36932Medicare UPIN
KY0359202Medicare ID - Type UnspecifiedMEDICARE
KY0762320Medicare ID - Type UnspecifiedMEDICARE
KY0358814Medicare ID - Type UnspecifiedMEDICARE
11574907OtherCAQH
KY000000044420OtherANTHEM
0026670Medicare ID - Type Unspecified
KY341172OtherTRICARE
KY0762223Medicare ID - Type UnspecifiedMEDICARE
KY0358913Medicare ID - Type UnspecifiedMEDICARE
KY30605018Medicaid