Provider Demographics
NPI:1659356210
Name:BUSH, CHARLES RALPH (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RALPH
Last Name:BUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1493 JEWETT RD
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-9735
Mailing Address - Country:US
Mailing Address - Phone:614-888-7468
Mailing Address - Fax:
Practice Address - Street 1:3525 OLENTANGY RIVER RD
Practice Address - Street 2:#5320
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3937
Practice Address - Country:US
Practice Address - Phone:614-263-9071
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH39197208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0435069Medicaid
OH0435069Medicaid
OHC01873Medicare UPIN
OH0480396Medicare ID - Type UnspecifiedMEDICARE