Healthcare Provider Details

I. General information

NPI: 1851931299
Provider Name (Legal Business Name): BUSH MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3156 WILLOWCREEK RD
PORTAGE IN
46368-4424
US

IV. Provider business mailing address

55 E 86TH AVE
MERRILLVILLE IN
46410-6382
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-4999
  • Fax:
Mailing address:
  • Phone: 219-769-1670
  • Fax: 219-738-6714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LYNN MCDONALD
Title or Position: CREDENTIALING
Credential:
Phone: 219-769-1670