Healthcare Provider Details

I. General information

NPI: 1073587291
Provider Name (Legal Business Name): PAUL MARTIN BUSSE PHD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BLOSSOM ST COX LL
BOSTON MA
02114-2617
US

IV. Provider business mailing address

PO BOX 9142 MASS GENERAL PHYSICIAN ORGANIZATION
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-1548
  • Fax: 617-724-8334
Mailing address:
  • Phone: 617-724-1548
  • Fax: 617-724-8334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number55649
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: