Individual
LISA C BUSHARDT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
105 THORNHILL DR, HATTIESBURG, MS 39402-1548
(601) 261-3737
(601) 261-3899
Mailing address
415 S 28TH AVE, HATTIESBURG, MS 39401-7246
(601) 261-3737
(601) 579-5240
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
12307
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00012749
—
MS
01
—
110028735
RAILROAD MEDICARE
—
05
—
1419877
—
LA
01
—
1558923
AMERICAN ADMIN GROUP
MS
Enumeration date
07/31/2006
Last updated
07/08/2020
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