Provider Demographics
NPI:1568417343
Name:BUSAM, MATTHEW L (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:BUSAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6045 BRIDGETOWN RD
Mailing Address - Street 2:STE 4
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45248-3049
Mailing Address - Country:US
Mailing Address - Phone:513-347-9999
Mailing Address - Fax:513-347-3999
Practice Address - Street 1:6045 BRIDGETOWN RD
Practice Address - Street 2:STE 4
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-3049
Practice Address - Country:US
Practice Address - Phone:513-347-9999
Practice Address - Fax:513-347-3999
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036115554207XX0005X
OH35.089716207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH221830Medicare PIN
OHBU4210742Medicare PIN
KY1239407Medicare PIN