Healthcare Provider Details

I. General information

NPI: 1316258874
Provider Name (Legal Business Name): SHANE DAVID BUSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 WILLOWCREEK RD
PORTAGE IN
46368-5075
US

IV. Provider business mailing address

3630 WILLOWCREEK RD
PORTAGE IN
46368-5075
US

V. Phone/Fax

Practice location:
  • Phone: 219-364-3700
  • Fax:
Mailing address:
  • Phone: 219-707-1185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01071914A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: