Healthcare Provider Details

I. General information

NPI: 1306993597
Provider Name (Legal Business Name): STEPHEN T. BUSHI, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 JUDITH LN SUITE 110
BOISE ID
83705-5235
US

IV. Provider business mailing address

1902 JUDITH LN SUITE 110
BOISE ID
83705-5235
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-379A
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-5492
License Number StateID

VIII. Authorized Official

Name: MRS. LORI A WILKINS
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-658-0800