Basic Information
Provider Information | |||||||||
NPI: | 1376894501 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RUSH-COPLEY MEDICAL GROUP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1256 WATERFORD DR STE 230 | ||||||||
Address2: |   | ||||||||
City: | AURORA | ||||||||
State: | IL | ||||||||
PostalCode: | 605044511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6304992404 | ||||||||
FaxNumber: | 6306925518 | ||||||||
Practice Location | |||||||||
Address1: | 2040 OGDEN AVE. | ||||||||
Address2: | SUITE 304 | ||||||||
City: | AURORA | ||||||||
State: | IL | ||||||||
PostalCode: | 60504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302364270 | ||||||||
FaxNumber: | 6302364271 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2012 | ||||||||
LastUpdateDate: | 02/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUMMEL | ||||||||
AuthorizedOfficialFirstName: | MARCEE | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6304992404 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RS0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 2083S0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Sports Medicine | 2081S0010X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 036-112492 | 05 | IL |   | MEDICAID |