Basic Information
| Provider Information | |||||||||
| NPI: | 1003830092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHNELL | ||||||||
| FirstName: | FREDERIC | ||||||||
| MiddleName: | RANSOM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | SHRINERS HOSPITALS FOR CHILDREN | ||||||||
| Address2: | PO BOX 8500 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191788113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818478 | ||||||||
| FaxNumber: | 8132818113 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 SOUTH FAIR OAKS AVENUE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263899300 | ||||||||
| FaxNumber: | 6263899336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A74349 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A743490 | 01 | CA | BLUE SHIELD | OTHER | 00A743490 | 05 | CA | MEDICAID | 00A743491 | 01 | CA | BLUE SHIELD | OTHER |