Provider Demographics
NPI:1568886422
Name:BUSH, JONATHAN WILLARD (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WILLARD
Last Name:BUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:LURIE CHILDREN'S HOSPITAL, BOX 17, DEPT OF PATHOLOGY
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:312-227-3973
Mailing Address - Fax:312-227-9616
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:LURIE CHILDREN'S HOSPITAL, BOX 17, DEPT OF PATHOLOGY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-3973
Practice Address - Fax:312-227-9616
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036134248207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology