Provider Demographics
NPI:1952332165
Name:BUSH, JOHN GREGORY (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGORY
Last Name:BUSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-054141207V00000X
IL036054141207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15928Medicare UPIN
IL964470Medicare PIN