MEDICARE: MR. JEREMY J BUSCH M.ED., ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1023021102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMY J BUSCH M.ED., ATC

Provider Business Mailing Address
First Line	:	1025 CUNNINGHAM DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-5931
Country	:	US
Telephone Number	:	970-491-0272
Fax Number	:	970-491-6167

Provider Business Practice Location Address
First Line	:	141 MOBY ARENA
Second Line	:	0120 ATHLETIC TRAINING
City	:	FORT COLLINS
State	:	CO
Zip	:	80523-0120
Country	:	US
Telephone Number	:	970-491-0272
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	07/08/2007

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