Basic Information
| Provider Information | |||||||||
| NPI: | 1487980538 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | M. THERESA RUSCH, M.D., INC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 396 W PUTNAM AVE | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932573323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597815022 | ||||||||
| FaxNumber: | 5597816990 | ||||||||
| Practice Location | |||||||||
| Address1: | 396 W PUTNAM AVE | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932573323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597815022 | ||||||||
| FaxNumber: | 5597816990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2009 | ||||||||
| LastUpdateDate: | 10/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | RUSCH | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | THERESA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5597815022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | C51083 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 00C51083 | 05 | CA | MEDICAID |