Healthcare Provider Details

I. General information

NPI: 1396081071
Provider Name (Legal Business Name): CARLA ANN BUZAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MADISON AVE
GRANITE CITY IL
62040-4701
US

IV. Provider business mailing address

35 OAKLAWN DR
GRANITE CITY IL
62040-3808
US

V. Phone/Fax

Practice location:
  • Phone: 618-798-3135
  • Fax: 618-798-3505
Mailing address:
  • Phone: 618-876-0019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070004264
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: