Provider Demographics
NPI:1467436931
Name:BUSICK, EDWARD JAMES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
Last Name:BUSICK
Suffix:JR
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 1:20 HOPE AVENUE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-2717
Mailing Address - Country:US
Mailing Address - Phone:781-647-0855
Mailing Address - Fax:781-647-9142
Practice Address - Street 1:20 HOPE AVENUE
Practice Address - Street 2:SUITE 211
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-2717
Practice Address - Country:US
Practice Address - Phone:781-647-0855
Practice Address - Fax:781-647-9142
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA40958207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2052334Medicaid
M09465OtherBLUE CROSS/BLUE SHIELD
MAC57282Medicare UPIN
C57282Medicare UPIN
MAM09465Medicare ID - Type UnspecifiedMEDICARE