Basic Information
| Provider Information | |||||||||
| NPI: | 1043334568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | NADINE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1842 SIMPSON HIGHWAY 149 | ||||||||
| Address2: | |||||||||
| City: | MENDENHALL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391143438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018472221 | ||||||||
| FaxNumber: | 6018477104 | ||||||||
| Practice Location | |||||||||
| Address1: | 1842 SIMPSON HIGHWAY 149 | ||||||||
| Address2: | |||||||||
| City: | MENDENHALL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391143438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018472221 | ||||||||
| FaxNumber: | 6018477104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MS16456 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00121967 | 05 | MS | MEDICAID |