Healthcare Provider Details

I. General information

NPI: 1306008230
Provider Name (Legal Business Name): SCOTT BUSSOM P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 SE MONTEREY RD STE 400
STUART FL
34994-4512
US

IV. Provider business mailing address

60 OLD NEW MILFORD RD STE 3E
BROOKFIELD CT
06804-2414
US

V. Phone/Fax

Practice location:
  • Phone: 772-288-2400
  • Fax:
Mailing address:
  • Phone: 203-775-6205
  • Fax: 203-775-2373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2964
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9114250
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: