Provider Demographics
NPI:1700801636
Name:RUTHERFORD EMERGENCY MEDICINE PA
Entity Type:Organization
Organization Name:RUTHERFORD EMERGENCY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR FOR GROUP
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-277-7772
Mailing Address - Street 1:PO BOX 75358
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-0358
Mailing Address - Country:US
Mailing Address - Phone:843-237-3378
Mailing Address - Fax:843-237-5073
Practice Address - Street 1:288 S RIDGECREST AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-2838
Practice Address - Country:US
Practice Address - Phone:843-237-3378
Practice Address - Fax:843-237-5073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCN/A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011R2Medicaid
NC011R2OtherBLUE CROSS BLUE SHIELD
NCCH4865OtherRAILROAD MEDICARE
NC89011R2Medicaid