Healthcare Provider Details

I. General information

NPI: 1568417343
Provider Name (Legal Business Name): MATTHEW L. BUSAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6045 BRIDGETOWN RD STE 4
CINCINNATI OH
45248-3049
US

IV. Provider business mailing address

6045 BRIDGETOWN RD STE 4
CINCINNATI OH
45248-3049
US

V. Phone/Fax

Practice location:
  • Phone: 513-347-9999
  • Fax: 513-347-3999
Mailing address:
  • Phone: 513-347-9999
  • Fax: 513-347-3999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036115554
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number35.089716
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: