Provider Demographics
NPI:1306993597
Name:STEPHEN T. BUSHI, M.D.
Entity type:Organization
Organization Name:STEPHEN T. BUSHI, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-658-0800
Mailing Address - Street 1:1902 JUDITH LN
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-5235
Mailing Address - Country:US
Mailing Address - Phone:208-658-0800
Mailing Address - Fax:
Practice Address - Street 1:1902 JUDITH LN
Practice Address - Street 2:SUITE 110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5235
Practice Address - Country:US
Practice Address - Phone:208-658-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-379A363LF0000X
IDM-54922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003533000Medicaid
IDA34557Medicare UPIN
ID003533000Medicaid