MEDICARE: FANG BU 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	35.133826	OH
2	208000000X	Pediatrics Physician	35.133826	OH
3	208000000X	Pediatrics Physician	34989	SC
4	208000000X	Pediatrics Physician	2009013425	MO
5	390200000X	Student in an Organized Health Care Education/Training Program	MD34989	SC
6	207ZP0213X	Pediatric Pathology Physician	67836	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962635193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANG BU M.D.

Provider Business Mailing Address
First Line	:	2525 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4518
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4518
Country	:	US
Telephone Number	:	612-813-6711
Fax Number	:	612-813-7721

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

Provider Enumeration Date	:	09/04/2009
Last Update Date	:	10/06/2020

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Directions to “ FANG BU M.D.” Practice Location

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