Provider Demographics
NPI:1811981756
Name:RUSH, JORDAN S (MD)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:S
Last Name:RUSH
Suffix:
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 1:3611 SHAMANS WALK
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1063
Mailing Address - Country:US
Mailing Address - Phone:404-434-7785
Mailing Address - Fax:
Practice Address - Street 1:10515 BELLS FERRY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-4204
Practice Address - Country:US
Practice Address - Phone:770-720-8551
Practice Address - Fax:770-345-2738
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA60319207V00000X
PAMD049482L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015986700005Medicaid
GA724164645AMedicaid
G22647Medicare UPIN
GA724164645AMedicaid