Provider Demographics
NPI:1821115171
Name:BUSH, JENNIFER ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELLEN
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 1:4895 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1926
Mailing Address - Country:US
Mailing Address - Phone:614-326-1502
Mailing Address - Fax:614-326-3011
Practice Address - Street 1:4895 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1926
Practice Address - Country:US
Practice Address - Phone:614-326-1502
Practice Address - Fax:614-326-3011
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.120702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083991Medicaid
OHH176130Medicare PIN