Provider Demographics
NPI:1336246727
Name:BUSSE, FRED (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:BUSSE
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 1:530 N. LAFAYETTE BLVD.
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1098
Mailing Address - Country:US
Mailing Address - Phone:574-234-4176
Mailing Address - Fax:574-234-1561
Practice Address - Street 1:530 N. LAFAYETTE BLVD.
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1098
Practice Address - Country:US
Practice Address - Phone:574-234-4176
Practice Address - Fax:574-234-1561
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027737A207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN738980SMedicare ID - Type UnspecifiedMEDICARE PROVIDER #
INE40946Medicare UPIN