1205848843 NPI number — RUSHMORE PHYSICAL THERAPY, P.A.

Table of content: (NPI 1205848843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205848843 NPI number — RUSHMORE PHYSICAL THERAPY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RUSHMORE PHYSICAL THERAPY, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205848843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORESTOWN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08057-0505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-764-0494
Provider Business Mailing Address Fax Number:
856-764-0580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1361 FAIRVIEW BLVD
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
DELRAN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08075-1473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-764-0494
Provider Business Practice Location Address Fax Number:
856-764-0580
Provider Enumeration Date:
08/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSHMORE
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
856-764-0494

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  40QAO0262900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 18155 . This is a "PA BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0444623000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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