Basic Information
Provider Information | |||||||||
NPI: | 1912944620 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUSCH | ||||||||
FirstName: | GERALD | ||||||||
MiddleName: | IRWIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 677 ALA MOANA BLVD STE 1001 | ||||||||
Address2: |   | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968135408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084694900 | ||||||||
FaxNumber: | 8085367315 | ||||||||
Practice Location | |||||||||
Address1: | 1356 LUSITANA ST FL 4 | ||||||||
Address2: |   | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968132409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8085862900 | ||||||||
FaxNumber: | 8085862940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2006 | ||||||||
LastUpdateDate: | 11/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084F0202X | MD-20623 | HI | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0800X | F9260 | TX | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | MD-20623 | HI | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0804X | MD-20623 | HI | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | MD-20623 | HI | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 1316226-01 | 05 | TX |   | MEDICAID | 10008925 | 01 |   | AMERIGROUP | OTHER | F67V | 01 |   | BCBS | OTHER |