=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649499757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG PATTON BUSHONG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 11/08/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6916 HIGHWAY 82
-----------------------------------------------------
City | GLENWOOD SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81601-9435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-945-2583
-----------------------------------------------------
Fax | 970-928-8852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 28 3/4 RD BLDG A
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81501-5016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-683-7107
-----------------------------------------------------
Fax | 970-683-7167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 51357
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 51357
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------