Healthcare Provider Details

I. General information

NPI: 1871706051
Provider Name (Legal Business Name): DAVID BUSSO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 N 64TH ST
BELLEVILLE IL
62223-3808
US

IV. Provider business mailing address

PO BOX 822344
PHILADELPHIA PA
19182-2344
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-0985
  • Fax: 908-653-9305
Mailing address:
  • Phone: 314-991-0985
  • Fax: 908-653-9305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number061688
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: