1760458863 NPI number — MR. BRIAN MARTIN BUSANICH M.S., A.T.C.

Table of content: MR. BRIAN MARTIN BUSANICH M.S., A.T.C. (NPI 1760458863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760458863 NPI number — MR. BRIAN MARTIN BUSANICH M.S., A.T.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSANICH
Provider First Name:
BRIAN
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S., A.T.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760458863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1503 W NELSON ST
Provider Second Line Business Mailing Address:
#3R
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60657-3116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-220-0812
Provider Business Mailing Address Fax Number:
708-222-5832

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1503 W NELSON ST
Provider Second Line Business Practice Location Address:
#3R
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60657-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-220-0812
Provider Business Practice Location Address Fax Number:
708-222-5832
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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