=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164452249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSH SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 02/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 648 CHETCO AVENUE
-----------------------------------------------------
City | BROOKINGS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-813-1835
-----------------------------------------------------
Fax | 541-813-1282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 94220 FOURTH STREET
-----------------------------------------------------
City | GOLD BEACH
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-247-3000
-----------------------------------------------------
Fax | 541-247-3101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.E.O.
-----------------------------------------------------
Name | VIRGINIA A. RAZO
-----------------------------------------------------
Credential | PHARM. D
-----------------------------------------------------
Telephone | 541-247-3108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 07-1579
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------