Provider Demographics
NPI:1063404358
Name:BUSSELL, GREGORY S (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:BUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 DEMPSTER ST STE 501
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8429
Mailing Address - Country:US
Mailing Address - Phone:847-674-5585
Mailing Address - Fax:
Practice Address - Street 1:2604 DEMPSTER ST STE 501
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8429
Practice Address - Country:US
Practice Address - Phone:847-674-5585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-103560207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-103560Medicaid
IL1063404358Medicare PIN
ILH34806Medicare UPIN