Basic Information
Provider Information | |||||||||
NPI: | 1023262391 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FREDERIC L BUSHKIN MD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 816759 | ||||||||
Address2: |   | ||||||||
City: | HOLLYWOOD | ||||||||
State: | FL | ||||||||
PostalCode: | 330810759 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549642450 | ||||||||
FaxNumber: | 9549646084 | ||||||||
Practice Location | |||||||||
Address1: | 3850 HOLLYWOOD BLVD | ||||||||
Address2: | SUITE 302 | ||||||||
City: | HOLLYWOOD | ||||||||
State: | FL | ||||||||
PostalCode: | 330216748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549642450 | ||||||||
FaxNumber: | 9549646084 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2008 | ||||||||
LastUpdateDate: | 11/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUSHKIN | ||||||||
AuthorizedOfficialFirstName: | FREDERIC | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9549642450 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.