Provider Demographics
NPI:1609885698
Name:RILEY-BUSSEY, ANNIE MARLENE (MD)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:MARLENE
Last Name:RILEY-BUSSEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4372 FERNCREEK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2525
Mailing Address - Country:US
Mailing Address - Phone:910-570-3113
Mailing Address - Fax:910-396-7271
Practice Address - Street 1:2864 WOODRUFF STREET
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28307
Practice Address - Country:US
Practice Address - Phone:910-570-3113
Practice Address - Fax:910-396-7271
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301070450207Q00000X
NC2009-01358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104412182Medicaid
MI104412164Medicaid
MI104412155Medicaid
MA104412173Medicaid
MI700H248710OtherBLUE CROSS GROUP NUMBER
MI104412146Medicaid