Basic Information
| Provider Information | |||||||||
| NPI: | 1891393435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUSH MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRIMARY CARE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5208 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393025208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039393 | ||||||||
| FaxNumber: | 6017033080 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 N HILLS ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393052643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014849906 | ||||||||
| FaxNumber: | 6014846704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2020 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | LARKIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6017039614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 00586260 | 05 | MS | MEDICAID |