Basic Information
| Provider Information | |||||||||
| NPI: | 1376501544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHKELL | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 SULPHUR SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378135654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233179344 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 2018 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379215718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655440406 | ||||||||
| FaxNumber: | 8655440480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | 13438 | TN | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 13438 | TN | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 3376258 | 05 | TN | MEDICAID | 0015500 | 01 | TN | BLUE CROSS | OTHER | 4034509 | 01 | TN | AETNA | OTHER |