Healthcare Provider Details

I. General information

NPI: 1669863122
Provider Name (Legal Business Name): BENJAMIN ANDREW BUSH CPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CATHERWOOD RD
ITHACA NY
14850-1056
US

IV. Provider business mailing address

40 CATHERWOOD RD
ITHACA NY
14850-1056
US

V. Phone/Fax

Practice location:
  • Phone: 607-257-0291
  • Fax: 607-216-6261
Mailing address:
  • Phone: 607-257-0291
  • Fax: 607-216-6261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: