MEDICARE: MARK B BUSCH OD

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	152W00000X	Optometrist	046.006948	IL

General Provider Information

NPI Number	:	1124167937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK B BUSCH OD

Provider Business Mailing Address
First Line	:	4005 167TH ST
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-2070
Country	:	US
Telephone Number	:	708-799-0920
Fax Number	:	708-798-1349

Provider Business Practice Location Address
First Line	:	4005 167TH ST
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-2070
Country	:	US
Telephone Number	:	708-799-0920
Fax Number	:	708-799-6310

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	03/20/2017

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