Provider Demographics
NPI:1144222399
Name:VANBUSSUM, ROBERT RITCHIE (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RITCHIE
Last Name:VANBUSSUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:R.
Other - Middle Name:RITCHIE
Other - Last Name:VAN BUSSUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1760 NICHOLASVILLE RD
Practice Address - Street 2:ST 603
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1471
Practice Address - Country:US
Practice Address - Phone:859-277-3636
Practice Address - Fax:859-277-7575
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64220650Medicaid
KY64220650Medicaid
KY0624433Medicare PIN
KY0672501Medicare PIN