Basic Information
| Provider Information | |||||||||
| NPI: | 1033149307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHNELL | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 OLIVE WAY MSC M4-PA | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981011873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065155811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 NE GILMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980272925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255578000 | ||||||||
| FaxNumber: | 4255578014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
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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 | 207Q00000X | MD00017470 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080067829 | 01 | RAILROAD MEDICARE | OTHER | B870 | 01 | WA | BLUE SHIELD | OTHER | 0039581 | 01 | WA | LABOR & INDUSTRY | OTHER | 175072 | 05 | WA | MEDICAID | US0818823 | 01 | WA | AETNA/USHC PCP | OTHER | US4119870 | 01 | WA | AETNA/USHC SPECIALIST | OTHER |