1679683742 NPI number — AGUSTINUS RUSHANAEDY MD

Table of content: AGUSTINUS RUSHANAEDY MD (NPI 1679683742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679683742 NPI number — AGUSTINUS RUSHANAEDY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSHANAEDY
Provider First Name:
AGUSTINUS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1679683742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90031-0309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-865-3700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6001 TRUXTUN AVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93309-0679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-323-6660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  OR MD 14298 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: MD 00033485 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: A41710 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208800000X , with the licence number: MD 10824 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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