MEDICARE: DR. CLINTON G BUSH III M.D.

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	207X00000X	Orthopaedic Surgery Physician	ME25660	FL

General Provider Information

NPI Number	:	1356347025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLINTON G BUSH III M.D.

Provider Business Mailing Address
First Line	:	1966 NE 123RD ST
Second Line	:	PMB#120
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2868
Country	:	US
Telephone Number	:	305-761-5571
Fax Number	:

Provider Business Practice Location Address
First Line	:	1966 NE 123RD ST
Second Line	:	PMB#120
City	:	NORTH MIAMI
State	:	FL
Zip	:	33181-2868
Country	:	US
Telephone Number	:	305-761-5571
Fax Number	:

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	08/29/2012

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