Healthcare Provider Details

I. General information

NPI: 1154574119
Provider Name (Legal Business Name): WILLIAM JEROME BUSH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

IV. Provider business mailing address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

V. Phone/Fax

Practice location:
  • Phone: 773-843-3000
  • Fax: 773-843-2704
Mailing address:
  • Phone: 773-843-3000
  • Fax: 773-843-2704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: