Provider Demographics
NPI:1184672511
Name:RUSH, BRIAN J (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:RUSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-940-9400
Mailing Address - Fax:
Practice Address - Street 1:2720 HOMESTEAD RD
Practice Address - Street 2:STE 100
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-4881
Practice Address - Country:US
Practice Address - Phone:435-940-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT326872-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTG84923Medicare UPIN
UT5534713Medicare ID - Type Unspecified