Provider Demographics
NPI:1679775423
Name:JOHN G. BUSH, DO LTD
Entity Type:Organization
Organization Name:JOHN G. BUSH, DO LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-469-6646
Mailing Address - Street 1:222 COLORADO AVE.
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1334
Mailing Address - Country:US
Mailing Address - Phone:815-469-6646
Mailing Address - Fax:815-469-6647
Practice Address - Street 1:222 COLORADO AVE.
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1334
Practice Address - Country:US
Practice Address - Phone:815-469-6646
Practice Address - Fax:815-469-6647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03654141207V00000X
IL036-054141207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL964470Medicare ID - Type Unspecified
ILD94002Medicare UPIN