MEDICARE: JONATHAN WILLARD BUSH M.D.

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	207ZP0213X	Pediatric Pathology Physician	036134248	IL

General Provider Information

NPI Number	:	1568886422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN WILLARD BUSH M.D.

Provider Business Mailing Address
First Line	:	225 E CHICAGO AVE
Second Line	:	LURIE CHILDREN'S HOSPITAL, BOX 17, DEPT OF PATHOLOGY
City	:	CHICAGO
State	:	IL
Zip	:	60611-2991
Country	:	US
Telephone Number	:	312-227-3973
Fax Number	:	312-227-9616

Provider Business Practice Location Address
First Line	:	225 E CHICAGO AVE
Second Line	:	LURIE CHILDREN'S HOSPITAL, BOX 17, DEPT OF PATHOLOGY
City	:	CHICAGO
State	:	IL
Zip	:	60611-2991
Country	:	US
Telephone Number	:	312-227-3973
Fax Number	:	312-227-9616

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

Provider Enumeration Date	:	02/13/2014
Last Update Date	:	02/13/2014

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