Provider Demographics
NPI:1265651822
Name:CHARLES BUSHONG, M D
Entity Type:Organization
Organization Name:CHARLES BUSHONG, M D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BUSHONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:973-625-7337
Mailing Address - Street 1:200 E MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-3614
Mailing Address - Country:US
Mailing Address - Phone:973-625-7337
Mailing Address - Fax:973-625-5796
Practice Address - Street 1:200 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-3614
Practice Address - Country:US
Practice Address - Phone:973-625-7337
Practice Address - Fax:973-625-5796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03472800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty