Provider Demographics
NPI:1376763946
Name:MARK H BUSSELL MD CPO PA
Entity Type:Organization
Organization Name:MARK H BUSSELL MD CPO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-346-7800
Mailing Address - Street 1:6116 OAKBEND TRL
Mailing Address - Street 2:SUITE 112
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3925
Mailing Address - Country:US
Mailing Address - Phone:817-732-0800
Mailing Address - Fax:817-596-5119
Practice Address - Street 1:6116 OAK BEND TRAIL
Practice Address - Street 2:STE 112
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4203
Practice Address - Country:US
Practice Address - Phone:817-346-7800
Practice Address - Fax:817-346-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0452208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T08WMedicare PIN
TXE97995Medicare UPIN