Basic Information
Provider Information
NPI: 1003141243
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RUSH
FirstName: STACY
MiddleName: LEIGH
NamePrefix: MRS.
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 14039
Address2:  
City: AUGUSTA
State: GA
PostalCode: 309190039
CountryCode: US
TelephoneNumber: 7068639797
FaxNumber: 7068607686
Practice Location
Address1: 3650 J DEWEY GRAY CIR
Address2:  
City: AUGUSTA
State: GA
PostalCode: 309091867
CountryCode: US
TelephoneNumber: 7068639797
FaxNumber: 7068607686
Other Information
ProviderEnumerationDate: 10/06/2009
LastUpdateDate: 10/06/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT007869GAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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