MEDICARE: MR. KEN MICHAEL RUSHFORD AT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AT002374	OH

General Provider Information

NPI Number	:	1750380945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEN MICHAEL RUSHFORD AT

Provider Business Mailing Address
First Line	:	4701 CREEK RD
Second Line	:	SUITE 110
City	:	CINCINNATI
State	:	OH
Zip	:	45242-8398
Country	:	US
Telephone Number	:	513-733-9333
Fax Number	:	513-588-2479

Provider Business Practice Location Address
First Line	:	4440 GLEN ESTE WITHAMSVILLE RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-1318
Country	:	US
Telephone Number	:	513-943-3630
Fax Number	:	513-753-4308

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	05/30/2013

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