Healthcare Provider Details

I. General information

NPI: 1124072251
Provider Name (Legal Business Name): TRACEY L BUSBY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DRIVE SUITE 105
KETCHUM ID
83340-0000
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-622-8811
  • Fax: 208-622-6921
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM7014
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: