Provider Demographics
NPI:1356336648
Name:BUSHI, STEPHEN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:THOMAS
Last Name:BUSHI
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 1:1902 JUDITH LN
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-5209
Mailing Address - Country:US
Mailing Address - Phone:208-658-0800
Mailing Address - Fax:208-323-1894
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:83705-5209
Practice Address - Country:US
Practice Address - Phone:208-658-0800
Practice Address - Fax:208-323-1894
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2018-02-13
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
IDM-54922084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003533000Medicaid
ID003533000Medicaid
ID1379244Medicare ID - Type Unspecified