Basic Information
| Provider Information | |||||||||
| NPI: | 1407888613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIERCE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RUSH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE | ||||||||
| Address2: | SUITE 2222 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723120 | ||||||||
| FaxNumber: | 5052728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722147 | ||||||||
| FaxNumber: | 5052729437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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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 | 207R00000X | F9108 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 81-286 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 81-286 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 2083P0901X | 81-286 | NM | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100152140A | 05 | OK | MEDICAID | 128961309 | 05 | TX | MEDICAID | F7736 | 05 | NM | MEDICAID |