Basic Information
| Provider Information | |||||||||
| NPI: | 1508831900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSH | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 FODEN RD WEST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078280361 | ||||||||
| FaxNumber: | 2078741483 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 FODEN ROAD WEST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075233900 | ||||||||
| FaxNumber: | 2075238593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 06/22/2011 | ||||||||
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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 | 207N00000X | 2005-00586 | NC | N | Allopathic & Osteopathic Physicians | Dermatology | 207NP0225X | 2005-00586 | NC | N | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 207NS0135X | 2005-00586 | NC | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | 017218 | ME | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.