Provider Demographics
NPI:1255389342
Name:RUSHDEN, RAYMOND OMAR (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:OMAR
Last Name:RUSHDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1736
Mailing Address - Street 2:140 STOLLINGS AVE SUITE 2
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601
Mailing Address - Country:US
Mailing Address - Phone:304-752-8400
Mailing Address - Fax:304-752-8419
Practice Address - Street 1:140 STOLLINGS AVE STE 2
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4035
Practice Address - Country:US
Practice Address - Phone:304-752-8400
Practice Address - Fax:304-752-8419
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV11444207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0128359000Medicaid
0513632Medicare ID - Type Unspecified
D49088Medicare UPIN