Healthcare Provider Details

I. General information

NPI: 1407201643
Provider Name (Legal Business Name): SAMANTHA MARIE BUSZEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA MARIE BITTER

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 S LAFOUNTAIN ST
KOKOMO IN
46902-3803
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 765-776-3020
  • Fax:
Mailing address:
  • Phone: 317-621-7584
  • Fax: 513-686-6868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01084725A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: