Provider Demographics
NPI:1568699239
Name:PROFESSIONAL HEALTH & MEDICAL SERVICES, P.C.
Entity Type:Organization
Organization Name:PROFESSIONAL HEALTH & MEDICAL SERVICES, P.C.
Other - Org Name:PROFESSIONAL HEALTH & MEDICAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-208-5222
Mailing Address - Street 1:720 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-1447
Mailing Address - Country:US
Mailing Address - Phone:810-664-8523
Mailing Address - Fax:810-664-8523
Practice Address - Street 1:720 4TH ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1447
Practice Address - Country:US
Practice Address - Phone:810-664-8523
Practice Address - Fax:810-664-8523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301405603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty