Provider Demographics
NPI:1154405546
Name:BUSH, JOHN T (C PED)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:T
Last Name:BUSH
Suffix:
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 MCFARLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3374
Mailing Address - Country:US
Mailing Address - Phone:205-339-4900
Mailing Address - Fax:205-339-4976
Practice Address - Street 1:945 MCFARLAND BLVD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3374
Practice Address - Country:US
Practice Address - Phone:205-339-4900
Practice Address - Fax:205-339-4976
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1499174400000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510 70415OtherBC/BS
AL11085100001Medicare ID - Type UnspecifiedMEDICARE