Healthcare Provider Details

I. General information

NPI: 1679775423
Provider Name (Legal Business Name): JOHN G. BUSH, DO LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 COLORADO AVE.
FRANKFORT IL
60423-1334
US

IV. Provider business mailing address

222 COLORADO AVE.
FRANKFORT IL
60423-1334
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-6646
  • Fax: 815-469-6647
Mailing address:
  • Phone: 815-469-6646
  • Fax: 815-469-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License Number036-054141
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number03654141
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN GREGORY BUSH
Title or Position: PRESIDENT
Credential: DO
Phone: 815-469-6646