Provider Demographics
NPI:1629167507
Name:BUSCH, KATHLEEN SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:SUE
Last Name:BUSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:SUE
Other - Last Name:VENNEKOTTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:487 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:43162-1178
Mailing Address - Country:US
Mailing Address - Phone:614-879-6622
Mailing Address - Fax:614-879-4043
Practice Address - Street 1:487 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:43162-1178
Practice Address - Country:US
Practice Address - Phone:614-879-6622
Practice Address - Fax:614-879-4043
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2271901Medicaid
OHH39196Medicare UPIN
OH2271901Medicaid