Healthcare Provider Details

I. General information

NPI: 1003830092
Provider Name (Legal Business Name): FREDERIC RANSOM BUSHNELL III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SOUTH FAIR OAKS AVENUE
PASADENA CA
91105-2625
US

IV. Provider business mailing address

SHRINERS HOSPITALS FOR CHILDREN PO BOX 8500
PHILADELPHIA PA
19178-8113
US

V. Phone/Fax

Practice location:
  • Phone: 626-389-9300
  • Fax: 626-389-9336
Mailing address:
  • Phone: 813-281-8478
  • Fax: 813-281-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA74349
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: