1033149307 NPI number — JEROME L BUSHNELL MD

Table of content: JEROME L BUSHNELL MD (NPI 1033149307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033149307 NPI number — JEROME L BUSHNELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSHNELL
Provider First Name:
JEROME
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033149307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 OLIVE WAY MSC M4-PA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98101-1873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-515-5811
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 NE GILMAN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-2925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-557-8000
Provider Business Practice Location Address Fax Number:
425-557-8014
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD00017470 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 080067829 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: B870 . This is a "BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0039581 . This is a "LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 175072 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: US0818823 . This is a "AETNA/USHC PCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: US4119870 . This is a "AETNA/USHC SPECIALIST" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com