Basic Information
| Provider Information | |||||||||
| NPI: | 1821004987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSSE | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 DEER TRACKS TRAIL | ||||||||
| Address2: | STE 130 | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148215600 | ||||||||
| FaxNumber: | 3148212180 | ||||||||
| Practice Location | |||||||||
| Address1: | 11133 DUNN ROAD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146534300 | ||||||||
| FaxNumber: | 3148212180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2085R0202X | 34803 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | IL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | L40183 | 01 | IL CARE | OTHER | 0006021895 | 01 | IL BLUE | OTHER | 0360497781 | 01 | IL CAID | OTHER | 25495 | 01 | BLUE CHOICE | OTHER | A12073 | 01 | GATE WAY | OTHER | 1390 | 01 | MO BLUE | OTHER | 2781 | 01 | GHP | OTHER | 5493 | 01 | HCARE USA | OTHER | 1082742 | 01 | MC MCAID | OTHER | 300378 | 01 | HLT PART | OTHER | 148419 | 01 | H LINK | OTHER | 1609024 | 01 | PH PLAN | OTHER |