Basic Information
| Provider Information | |||||||||
| NPI: | 1861451247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAVURU | ||||||||
| FirstName: | BUSH | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1705 TARBORO ST SW | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278933428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523998040 | ||||||||
| FaxNumber: | 2523998829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 TARBORO ST SW | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278933428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523998040 | ||||||||
| FaxNumber: | 2523998829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 08/12/2011 | ||||||||
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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 | 174400000X | 97-01789 | NC | N | Other Service Providers | Specialist | 2084P0800X | 0101-242842 | VA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 891157U | 05 | NC | MEDICAID |