Basic Information
| Provider Information | |||||||||
| NPI: | 1447437082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | GEARY | ||||||||
| MiddleName: | DILLON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357445 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705362323 | ||||||||
| FaxNumber: | 7705364947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2008 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 002382 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 66361 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 003126782N | 05 | GA | MEDICAID | 01994631 | 01 | GA | AMERIGROUP | OTHER | 003126782A | 05 | GA | MEDICAID |