Basic Information
Provider Information | |||||||||
NPI: | 1780764357 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUSCH | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUSCH | ||||||||
OtherFirstName: | JAMES | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1702 MEDICAL PARK DR W | ||||||||
Address2: | PO BOX 3409 | ||||||||
City: | WILSON | ||||||||
State: | NC | ||||||||
PostalCode: | 278932705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2522437944 | ||||||||
FaxNumber: | 2522436097 | ||||||||
Practice Location | |||||||||
Address1: | 1702 MEDICAL PARK DR W | ||||||||
Address2: |   | ||||||||
City: | WILSON | ||||||||
State: | NC | ||||||||
PostalCode: | 278932705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2522437944 | ||||||||
FaxNumber: | 2522436097 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 208000000X | 27662 | NC | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 8920433 | 05 | NC |   | MEDICAID |