Healthcare Provider Details

I. General information

NPI: 1629334982
Provider Name (Legal Business Name): ELISA THELYS BUSHMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 LIBERTY AVE STE GR59
PITTSBURGH PA
15224-2156
US

IV. Provider business mailing address

4815 LIBERTY AVE STE GR59
PITTSBURGH PA
15224-2156
US

V. Phone/Fax

Practice location:
  • Phone: 412-578-3951
  • Fax: 412-578-1587
Mailing address:
  • Phone: 412-578-3951
  • Fax: 412-578-1587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberMD473449
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: