Provider Demographics
NPI:1003830092
Name:BUSHNELL, FREDERIC RANSOM III (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:RANSOM
Last Name:BUSHNELL
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SHRINERS HOSPITALS FOR CHILDREN
Mailing Address - Street 2:PO BOX 8500
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-8113
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-281-8113
Practice Address - Street 1:909 SOUTH FAIR OAKS AVENUE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2625
Practice Address - Country:US
Practice Address - Phone:626-389-9300
Practice Address - Fax:626-389-9336
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74349207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A743490OtherBLUE SHIELD
CA00A743490Medicaid
CA00A743491OtherBLUE SHIELD
CAWA74349BMedicare PIN
CAA74349Medicare PIN
CA00A743491OtherBLUE SHIELD
CA00A743490Medicaid