Provider Demographics
NPI:1376226001
Name:BUSHMANN, BLAINE KENDELL (HIS)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:KENDELL
Last Name:BUSHMANN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 S BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4027
Mailing Address - Country:US
Mailing Address - Phone:660-956-9156
Mailing Address - Fax:660-956-9151
Practice Address - Street 1:915 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4027
Practice Address - Country:US
Practice Address - Phone:660-956-9156
Practice Address - Fax:660-956-9151
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023031557237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist