Basic Information
| Provider Information | |||||||||
| NPI: | 1366439846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSHYHEAD | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 MINOR AVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063869500 | ||||||||
| FaxNumber: | 2065763802 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 MINOR AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063869500 | ||||||||
| FaxNumber: | 2063869605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00013282 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8152340 | 05 | WA | MEDICAID | 5891740001 | 01 | WA | DME | OTHER | 49321 | 01 | WA | L & I | OTHER | BU5332 | 01 | WA | REGENCE | OTHER |