MEDICARE: LORI BUBASH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	4301080761	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	300F362420	OTHER	MI	BCBSM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417916602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI BUBASH

Provider Business Mailing Address
First Line	:	6816 VALLEY SPRING RD
Second Line	:
City	:	BLOOMFIELD
State	:	MI
Zip	:	48301-2845
Country	:	US
Telephone Number	:	248-255-1941
Fax Number	:

Provider Business Practice Location Address
First Line	:	6816 VALLEY SPRING RD
Second Line	:
City	:	BLOOMFIELD
State	:	MI
Zip	:	48301-2845
Country	:	US
Telephone Number	:	248-255-1941
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	04/10/2023

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Directions to “ LORI BUBASH ” Practice Location

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