Provider Demographics
NPI:1487825162
Name:RONALD B BUSH MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RONALD B BUSH MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-200-2992
Mailing Address - Street 1:PO BOX 13430
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92255-3430
Mailing Address - Country:US
Mailing Address - Phone:760-200-2992
Mailing Address - Fax:760-200-2993
Practice Address - Street 1:45280 CLUB DR
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-8860
Practice Address - Country:US
Practice Address - Phone:760-200-2992
Practice Address - Fax:760-200-2993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-20
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA553069174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A5530691Medicaid
CA00A5530691Medicaid
CAE41799Medicare UPIN