Basic Information
| Provider Information | |||||||||
| NPI: | 1598252629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSHEY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | VANCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4525 CAMERON VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282114369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043555100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2018 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2021-02975 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.