Provider Demographics
NPI:1205839503
Name:BUSACCO, BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:BUSACCO
Suffix:
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 1:2060 READING RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1454
Mailing Address - Country:US
Mailing Address - Phone:513-721-3200
Mailing Address - Fax:513-639-3186
Practice Address - Street 1:7495 STATE RD
Practice Address - Street 2:STE 325
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-6404
Practice Address - Country:US
Practice Address - Phone:513-233-2000
Practice Address - Fax:513-624-2684
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048242B207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH287923OtherAMERIGROUP
OH0511655Medicaid
OH0720620OtherUNITED HEALTHCARE
OH1023323OtherAETNA
OH31157505103OtherCARESOURCE
OH000000020974OtherANTHEM
OH000000020974OtherANTHEM
OH31157505103OtherCARESOURCE