MEDICARE: MARK H BUSSELL MD CPO PA

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	208100000X	Physical Medicine & Rehabilitation Physician	J0452	TX

General Provider Information

NPI Number	:	1376763946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK H BUSSELL MD CPO PA

Provider Business Mailing Address
First Line	:	6116 OAKBEND TRL
Second Line	:	SUITE 112
City	:	FT WORTH
State	:	TX
Zip	:	76132-3925
Country	:	US
Telephone Number	:	817-732-0800
Fax Number	:	817-596-5119

Provider Business Practice Location Address
First Line	:	6116 OAK BEND TRAIL
Second Line	:	STE 112
City	:	FT WORTH
State	:	TX
Zip	:	76132-4203
Country	:	US
Telephone Number	:	817-346-7800
Fax Number	:	817-346-7804

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MS. RUTH A GOLDEN
Credential	:
Telephone Number	:	817-346-7800

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	11/23/2011

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