Provider Demographics
NPI:1124086434
Name:RUSHTON, JERRY L (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:RUSHTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-963-2720
Mailing Address - Fax:
Practice Address - Street 1:705 BARNHILL DR
Practice Address - Street 2:#1300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-944-2801
Practice Address - Fax:317-944-5630
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01057495A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200114380Medicaid
KY64065642Medicaid
INM400065079Medicare PIN
ING46336Medicare UPIN
145590H2Medicare PIN
IN264430285Medicare PIN