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General NPI Number Information
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NPI Number | 1265651822
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Entity Type | Organization
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Legal Business Name | CHARLES BUSHONG, M D
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 200 E MAIN ST SUITE C
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City | ROCKAWAY
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State | NJ
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Zip | 07866-3614
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Country | US
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Telephone | 973-625-7337
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Fax | 973-625-5796
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Provider Business Mailing Address
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Address Line | 200 E MAIN ST SUITE C
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City | ROCKAWAY
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State | NJ
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Zip | 07866-3614
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Country | US
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Telephone | 973-625-7337
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Fax | 973-625-5796
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Authorized Official
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Title or Position | OWNER
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Name | CHARLES ROBERT BUSHONG JR.
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Credential | MD
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Telephone | 973-625-7337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 25MA03472800
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License Number State | NJ
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