Healthcare Provider Details

I. General information

NPI: 1356336648
Provider Name (Legal Business Name): STEPHEN THOMAS BUSHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

1902 JUDITH LN SUITE 110
BOISE ID
83705-5209
US

IV. Provider business mailing address

1902 JUDITH LN SUITE 110
BOISE ID
83705-5209
US

V. Phone/Fax

Practice location:
  • Phone: 208-658-0800
  • Fax: 208-323-1894
Mailing address:
  • Phone: 208-658-0800
  • Fax: 208-323-1894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-5492
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberM-5492
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: