Basic Information
| Provider Information | |||||||||
| NPI: | 1962791731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSSEY | ||||||||
| FirstName: | CAMRA | ||||||||
| MiddleName: | BETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775383 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123765315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3201 MIDDLE RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472034427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123728281 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2011 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 11015985A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.