Provider Demographics
NPI:1316096399
Name:BUSHNELL FAMILY PRACTICE, SC
Entity type:Organization
Organization Name:BUSHNELL FAMILY PRACTICE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-772-9444
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-0446
Mailing Address - Country:US
Mailing Address - Phone:309-833-2868
Mailing Address - Fax:309-836-3779
Practice Address - Street 1:155 W HAIL ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:IL
Practice Address - Zip Code:61422-1346
Practice Address - Country:US
Practice Address - Phone:309-772-9444
Practice Address - Fax:309-772-6446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062336Medicaid
IL5515957OtherBLUE CROSS BLUE SHIELD
IL148952OtherMEDICARE PART A
IL014509OtherHEALTH ALLIANCE
ILC42743Medicare UPIN
IL036062336Medicaid