Basic Information
Provider Information | |||||||||
NPI: | 1477670966 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RUSH MEDICAL FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | H.C. WATKINS MEMORIAL HOSPITAL SWING BED | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5208 | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393025208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017039393 | ||||||||
FaxNumber: | 6017033080 | ||||||||
Practice Location | |||||||||
Address1: | 605 S ARCHUSA AVE | ||||||||
Address2: |   | ||||||||
City: | QUITMAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393552331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017766925 | ||||||||
FaxNumber: | 6017767147 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2007 | ||||||||
LastUpdateDate: | 04/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KENNEDY | ||||||||
AuthorizedOfficialFirstName: | DON | ||||||||
AuthorizedOfficialMiddleName: | LARKIN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6017039614 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X |   |   | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
ID Information
ID | Type | State | Issuer | Description | 00029005 | 05 | MS |   | MEDICAID |