Basic Information
| Provider Information | |||||||||
| NPI: | 1295040582 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFF W BUSH, M.D,, FAMILY PRACTICE LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 617 E BROAD ST | ||||||||
| Address2: | STE A | ||||||||
| City: | EUFAULA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360271710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346873836 | ||||||||
| FaxNumber: | 3346870725 | ||||||||
| Practice Location | |||||||||
| Address1: | 617 E BROAD ST | ||||||||
| Address2: | STE A | ||||||||
| City: | EUFAULA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360271710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346873836 | ||||||||
| FaxNumber: | 3346870725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2010 | ||||||||
| LastUpdateDate: | 08/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | BUSH | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3346873836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19771 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 515-98558 | 01 | AL | BCBS OF ALABAMA | OTHER |