Provider Demographics
NPI:1710945076
Name:RUSH ORTHOPEDIC AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:RUSH ORTHOPEDIC AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:601-703-9231
Mailing Address - Street 1:P.O. DRAWER 1930
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-1930
Mailing Address - Country:US
Mailing Address - Phone:601-703-9506
Mailing Address - Fax:601-703-3264
Practice Address - Street 1:1800 12TH ST
Practice Address - Street 2:SUITE 1C
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4158
Practice Address - Country:US
Practice Address - Phone:601-703-9231
Practice Address - Fax:601-703-4476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
209001400OtherUS DEPT OF LABOR W/C
DA7584OtherRAILROAD MEDICARE
AL529917900Medicaid
AL529917900Medicaid
=========OtherTRICARE
C03008Medicare ID - Type Unspecified