Provider Demographics
NPI:1093950941
Name:BUSH, AMANDA JO (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:JO
Last Name:BUSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 78866 SWEDISHAMERICAN MEDICAL GROUP
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:779-696-7342
Practice Address - Street 1:1700 HENRY LUCKOW LN
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008
Practice Address - Country:US
Practice Address - Phone:779-696-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-06
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3526207V00000X, 207VG0400X
MAMB0755263A207VG0400X
IL036.125964207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL436860071Medicare PIN