Basic Information
| Provider Information | |||||||||
| NPI: | 1689224362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSCH | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPM STUDENT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HATZINGER | ||||||||
| OtherFirstName: | SHELBY | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPM STUDENT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | LEGACY GOOD SAMARITAN MEDICAL CENTER- GME | ||||||||
| Address2: | 1015 NW 22ND AVE | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034138401 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | LEGACY GOOD SAMARITAN MEDICAL CENTER- GME | ||||||||
| Address2: | 1015 NW 22ND AVE | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034138401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2019 | ||||||||
| LastUpdateDate: | 03/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.