Healthcare Provider Details

I. General information

NPI: 1699088906
Provider Name (Legal Business Name): JEREMY C BUSHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONROE AVE NW
GRAND RAPIDS MI
49503-1455
US

IV. Provider business mailing address

2060 EAST PARIS SEAVE 100
GRAND RAPIDS MI
49546-6113
US

V. Phone/Fax

Practice location:
  • Phone: 616-732-6200
  • Fax:
Mailing address:
  • Phone: 616-464-4610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301096488
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: