Basic Information
| Provider Information | |||||||||
| NPI: | 1659712008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUI | ||||||||
| FirstName: | TUAN | ||||||||
| MiddleName: | ANH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUI | ||||||||
| OtherFirstName: | MICKEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 180 HARVESTER DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605274503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737021150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 649 SHORE RD | ||||||||
| Address2: | |||||||||
| City: | SOMERS POINT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082442449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093656239 | ||||||||
| FaxNumber: | 6093655305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2013 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MT204497 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 036146145 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0709352 | 05 | NJ | MEDICAID |