Provider Demographics
NPI:1235360165
Name:BUSSELL, AVIDA NUBIA (MD)
Entity Type:Individual
Prefix:DR
First Name:AVIDA
Middle Name:NUBIA
Last Name:BUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17800 KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2029
Mailing Address - Country:US
Mailing Address - Phone:708-213-4200
Mailing Address - Fax:
Practice Address - Street 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3201
Practice Address - Country:US
Practice Address - Phone:219-326-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.05539207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine