Provider Demographics
NPI:1033149307
Name:BUSHNELL, JEROME L (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:L
Last Name:BUSHNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 OLIVE WAY MSC M4-PA
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:206-515-5811
Mailing Address - Fax:
Practice Address - Street 1:100 NE GILMAN BLVD
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2925
Practice Address - Country:US
Practice Address - Phone:425-557-8000
Practice Address - Fax:425-557-8014
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080067829OtherRAILROAD MEDICARE
WAB870OtherBLUE SHIELD
WA0039581OtherLABOR & INDUSTRY
WA175072Medicaid
WAUS0818823OtherAETNA/USHC PCP
WAUS4119870OtherAETNA/USHC SPECIALIST
WA000184205Medicare PIN
WAUS4119870OtherAETNA/USHC SPECIALIST
WA175072Medicaid
WA8850552Medicare PIN