Provider Demographics
NPI:1548235492
Name:BUSH, MORIA NICHOLS (MD)
Entity Type:Individual
Prefix:DR
First Name:MORIA
Middle Name:NICHOLS
Last Name:BUSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 FOUNTAIN CT
Mailing Address - Street 2:SUITE 260
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1895
Mailing Address - Country:US
Mailing Address - Phone:859-264-0660
Mailing Address - Fax:859-264-0662
Practice Address - Street 1:230 FOUNTAIN CT
Practice Address - Street 2:SUITE 260
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1895
Practice Address - Country:US
Practice Address - Phone:859-264-0660
Practice Address - Fax:859-264-0662
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30550208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65944761Medicaid
KY000000392673OtherANTHEM
KY64305501Medicaid
KY56079Medicare ID - Type Unspecified
KYG37695Medicare UPIN