Provider Demographics
NPI:1427077908
Name:BUSH, JEFFREY LANE (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LANE
Last Name:BUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3696 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 DANTIGNAC ST STE 1000
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2776
Practice Address - Country:US
Practice Address - Phone:068-212-9447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051300207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA66 BBBFXMedicare ID - Type Unspecified
GAH 00655Medicare UPIN