=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205848843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSHMORE PHYSICAL THERAPY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 10/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1361 FAIRVIEW BLVD SUITE J
-----------------------------------------------------
City | DELRAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08075-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-764-0494
-----------------------------------------------------
Fax | 856-764-0580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 505
-----------------------------------------------------
City | MOORESTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08057-0505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-764-0494
-----------------------------------------------------
Fax | 856-764-0580
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JAMES H RUSHMORE
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 856-764-0494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 40QAO0262900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------