Provider Demographics
NPI:1124072251
Name:BUSBY, TRACEY L (MD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:L
Last Name:BUSBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 105
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-0000
Practice Address - Country:US
Practice Address - Phone:208-622-8811
Practice Address - Fax:208-622-6921
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003576900Medicaid
IDP00659676OtherMCRR
ID003576900Medicaid
ID20001831Medicare PIN
F96410Medicare UPIN