Provider Demographics
NPI:1447598032
Name:BUSH, BILLY RAY
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:RAY
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 1:55 S STATE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-3802
Mailing Address - Country:US
Mailing Address - Phone:903-742-6120
Mailing Address - Fax:
Practice Address - Street 1:55 S STATE AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-3802
Practice Address - Country:US
Practice Address - Phone:903-742-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies