Basic Information
| Provider Information | |||||||||
| NPI: | 1316987969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUTHERFORD | ||||||||
| FirstName: | JOLEE | ||||||||
| MiddleName: | BOSTICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 W POPLAR AVE | ||||||||
| Address2: | |||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380170601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018619000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 27409 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 14653 | MS | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4028377 | 01 | TN | BLUE CROSS | OTHER | 00125126 | 05 | MS | MEDICAID | 3837440 | 05 | TN | MEDICAID |