MEDICARE: RONALD DARRELL BUSH II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1134925548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD DARRELL BUSH II

Provider Business Mailing Address
First Line	:	4121 SAINT AUBIN ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-1406
Country	:	US
Telephone Number	:	313-969-5199
Fax Number	:

Provider Business Practice Location Address
First Line	:	4121 SAINT AUBIN ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-1406
Country	:	US
Telephone Number	:	313-969-5199
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2025
Last Update Date	:	02/25/2025

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