1467400952 NPI number — DR. NICOLE A RUSH OD

Table of content: DR. NICOLE A RUSH OD (NPI 1467400952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467400952 NPI number — DR. NICOLE A RUSH OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSH
Provider First Name:
NICOLE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ERENFELD
Provider Other First Name:
NICOLE
Provider Other Middle Name:
RUSH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467400952
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 956
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANDON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-347-3622
Provider Business Mailing Address Fax Number:
541-347-2872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1095 ALABAMA AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANDON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-347-3622
Provider Business Practice Location Address Fax Number:
541-347-2872
Provider Enumeration Date:
05/05/2006

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: 152W00000X , with the licence number:  2856ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 227958 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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