=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376297903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSH SURGICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2022
-----------------------------------------------------
Last Update Date | 02/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 PLANTATION GROVE BLVD
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-451-2568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 PLANTATION GROVE BLVD
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78572-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-451-2568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | SERGIO J LOPEZ
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 956-451-2568
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------