Healthcare Provider Details

I. General information

NPI: 1073516829
Provider Name (Legal Business Name): EVERETT M BUSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 N MCCORD RD
TOLEDO OH
43615-1753
US

IV. Provider business mailing address

2940 N MCCORD RD
TOLEDO OH
43615-1753
US

V. Phone/Fax

Practice location:
  • Phone: 419-842-3094
  • Fax: 419-842-3048
Mailing address:
  • Phone: 419-842-3094
  • Fax: 419-842-3048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35034799B
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301050060
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: