Provider Demographics
NPI:1265452783
Name:THE BUSCH CLINIC, P.C.
Entity Type:Organization
Organization Name:THE BUSCH CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:618-222-7277
Mailing Address - Street 1:4460 N ILLINOIS ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-1899
Mailing Address - Country:US
Mailing Address - Phone:618-222-7277
Mailing Address - Fax:618-222-7305
Practice Address - Street 1:4460 N ILLINOIS ST
Practice Address - Street 2:SUITE 7
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1899
Practice Address - Country:US
Practice Address - Phone:618-222-7277
Practice Address - Fax:618-222-7305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149009826251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK17454Medicare UPIN
IL211639Medicare ID - Type Unspecified