Basic Information
| Provider Information | |||||||||
| NPI: | 1710945076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUSH ORTHOPEDIC AND SPORTS MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. DRAWER 1930 | ||||||||
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| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393021930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039506 | ||||||||
| FaxNumber: | 6017033264 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 12TH ST | ||||||||
| Address2: | SUITE 1C | ||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039231 | ||||||||
| FaxNumber: | 6017034476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 02/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | RUSH | ||||||||
| AuthorizedOfficialFirstName: | GUSTAVUS | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6017039231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 209001400 | 01 | US DEPT OF LABOR W/C | OTHER | DA7584 | 01 | RAILROAD MEDICARE | OTHER | 529917900 | 05 | AL | MEDICAID |