Provider Demographics
NPI:1518548601
Name:BUSH, GWENDOLYN D
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:D
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23195 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-7301
Mailing Address - Country:US
Mailing Address - Phone:954-806-9411
Mailing Address - Fax:
Practice Address - Street 1:23195 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-7301
Practice Address - Country:US
Practice Address - Phone:954-806-9411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9521503Medicaid