=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891165734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSHING ANCILLARY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2015
-----------------------------------------------------
Last Update Date | 10/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5005 LIVE OAK ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75402-6364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-455-3500
-----------------------------------------------------
Fax | 903-455-3509
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5005 LIVE OAK ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75402-6364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-455-3500
-----------------------------------------------------
Fax | 903-455-3509
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN OWNER
-----------------------------------------------------
Name | GINA S RUSHING
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 903-455-3500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | K6283
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------