Healthcare Provider Details

I. General information

NPI: 1255389342
Provider Name (Legal Business Name): RAYMOND OMAR RUSHDEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 STOLLINGS AVE STE 2
LOGAN WV
25601-4035
US

IV. Provider business mailing address

PO BOX 1736 140 STOLLINGS AVE SUITE 2
LOGAN WV
25601
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-8400
  • Fax: 304-752-8419
Mailing address:
  • Phone: 304-752-8400
  • Fax: 304-752-8419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number11444
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: