Provider Demographics
NPI:1740483692
Name:FORREST KENTON BUSCH, D.O. P.C.
Entity type:Organization
Organization Name:FORREST KENTON BUSCH, D.O. P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-286-4300
Mailing Address - Street 1:1950 COOK ST
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024
Mailing Address - Country:US
Mailing Address - Phone:731-286-4300
Mailing Address - Fax:731-286-8008
Practice Address - Street 1:1950 COOK ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-286-4300
Practice Address - Fax:731-286-8008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000000839207K00000X, 207N00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3303355Medicaid
TN3303355Medicaid