Healthcare Provider Details

I. General information

NPI: 1831927250
Provider Name (Legal Business Name): BUSOLE CHARLOTTE MASSUNKEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/28/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S CENTRAL AVE
CHICAGO IL
60644-5059
US

IV. Provider business mailing address

645 S CENTRAL AVE
CHICAGO IL
60644-5059
US

V. Phone/Fax

Practice location:
  • Phone: 773-626-4300
  • Fax:
Mailing address:
  • Phone: 773-626-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number125084893
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: