Basic Information
| Provider Information | |||||||||
| NPI: | 1295790780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500 | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107151010 | ||||||||
| FaxNumber: | 9107151926 | ||||||||
| Practice Location | |||||||||
| Address1: | VA MEDICAL CENTER, MOUNTAIN HOME | ||||||||
| Address2: | SIDNEY AND LAMONT ST | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
| FaxNumber: | 4239792829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 10/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 17658 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | 2015-00086 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.