MEDICARE: MR. BRIAN MARTIN BUSANICH M.S., A.T.C.

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	2255A2300X	Athletic Trainer		IL

General Provider Information

NPI Number	:	1760458863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN MARTIN BUSANICH M.S., A.T.C.

Provider Business Mailing Address
First Line	:	1503 W NELSON ST
Second Line	:	#3R
City	:	CHICAGO
State	:	IL
Zip	:	60657-3116
Country	:	US
Telephone Number	:	773-220-0812
Fax Number	:	708-222-5832

Provider Business Practice Location Address
First Line	:	1503 W NELSON ST
Second Line	:	#3R
City	:	CHICAGO
State	:	IL
Zip	:	60657-3116
Country	:	US
Telephone Number	:	773-220-0812
Fax Number	:	708-222-5832

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	07/08/2007

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