Provider Demographics
NPI:1083704837
Name:BUSH, KIMBERLY MONIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MONIQUE
Last Name:BUSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6818
Mailing Address - Country:US
Mailing Address - Phone:704-443-8755
Mailing Address - Fax:
Practice Address - Street 1:448 LAKESHORE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4264
Practice Address - Country:US
Practice Address - Phone:803-329-3177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-002092084P0804X
SC259472084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry