Provider Demographics
NPI:1760411623
Name:BUSH, ROGER W (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:BUSH
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 9TH AVE
Mailing Address - Street 2:MS M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-583-6025
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019262207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8101636Medicaid
WAB868OtherBLUE SHIELD
WAUS4119874OtherAETNA/USHC SPECIALIST
WA0030012OtherLABOR & INDUSTRY
110195638OtherRAILROAD MEDICARE
WAMD9262OtherALASKA MEDICAID
WAUS0899731OtherAETNA/USHC PCP
WAMD9262OtherALASKA MEDICAID
WA000181713Medicare PIN
WA8851037Medicare PIN