Provider Demographics
NPI:1194825323
Name:RUSHTON, FRED WALLACE JR (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:WALLACE
Last Name:RUSHTON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6426
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-925-6805
Practice Address - Fax:601-926-4978
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS062372086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0013429Medicaid
MS020046786 GRPCG6446OtherRAILROAD MEDICARE
AL158101Medicaid
MSP00462318OtherRR MEDICARE
MS302I775653Medicare PIN
MS0013429Medicaid
MS020046786 GRPCG6446OtherRAILROAD MEDICARE
MS512I770003Medicare PIN