Basic Information
| Provider Information | |||||||||
| NPI: | 1164452249 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUSH SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 94220 FOURTH STREET | ||||||||
| Address2: | |||||||||
| City: | GOLD BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412473000 | ||||||||
| FaxNumber: | 5412473101 | ||||||||
| Practice Location | |||||||||
| Address1: | 648 CHETCO AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKINGS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418131835 | ||||||||
| FaxNumber: | 5418131282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 02/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | RAZO | ||||||||
| AuthorizedOfficialFirstName: | VIRGINIA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 5412473108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CURRY HEALTH DISTRICT | ||||||||
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| AuthorizedOfficialCredential: | PHARM. D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 07-1579 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 240088 | 05 | OR | MEDICAID |