Healthcare Provider Details

I. General information

NPI: 1760458863
Provider Name (Legal Business Name): BRIAN MARTIN BUSANICH M.S., A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 W NELSON ST #3R
CHICAGO IL
60657-3116
US

IV. Provider business mailing address

1503 W NELSON ST #3R
CHICAGO IL
60657-3116
US

V. Phone/Fax

Practice location:
  • Phone: 773-220-0812
  • Fax: 708-222-5832
Mailing address:
  • Phone: 773-220-0812
  • Fax: 708-222-5832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: