MEDICARE: DR. CHARLES A BUSH-JOSEPH 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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	01079047A	IN
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	036070386	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	207073	OTHER	IL	MEDICARE PTAN LOCALITY 15
3	207067	OTHER	IL	MEDICARE PTAN LOCALITY 16
4	P00202615	OTHER		RAILROAD MEDICARE
5	DA4902	OTHER		RAILROAD MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4120999	OTHER		AETNA

General Provider Information

NPI Number	:	1821077736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES A BUSH-JOSEPH M.D.

Provider Business Mailing Address
First Line	:	1611 W HARRISON ST STE 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-4861
Country	:	US
Telephone Number	:	877-632-6637
Fax Number	:	708-409-5179

Provider Business Practice Location Address
First Line	:	1611 W HARRISON ST STE 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-4861
Country	:	US
Telephone Number	:	877-632-6637
Fax Number	:	708-409-5179

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

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	09/18/2023

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Directions to “ DR. CHARLES A BUSH-JOSEPH M.D.” Practice Location

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