<h3>Purpose/Objective(s)</h3> Radiation therapy and surgery are fundamental site-directed therapies for localized rectal cancer. To understand the relationship between rurality and access to specialized care, we characterized the association of rural patient residence with receipt of surgery and adjuvant radiation therapy among Medicare beneficiaries with rectal cancer. <h3>Materials/Methods</h3> We identified fee-for-service Medicare beneficiaries aged 65 or older diagnosed with non-metastatic rectal cancer from 2016 to 2018. Beneficiary place of residence was assigned to one of three categories (metropolitan, micropolitan, or small town/rural) based on census tract and corresponding Rural Urban Commuting Area codes. Multivariable regression models were used to determine associations between levels of rurality and receipt of both radiation and surgery within 180 days of diagnosis. In addition, we explored associations between patient rurality and characteristics of surgery and radiation such as minimally invasive surgery and intensity modulated radiation therapy (IMRT). <h3>Results</h3> Of 13,237 FFS Medicare beneficiaries with non-metastatic rectal cancer, 897 (6.8%) underwent both radiation and surgery within 180 days of diagnosis. For the entire rectal cancer cohort, small town/rural residence was associated with an increased likelihood of receiving both radiation and surgery within 180 days of diagnosis (Adjusted sub-hazard ratio (SHR) 1.27; 95%CI 1.07 – 1.52). Among patients who did receive surgery, no differences were observed in receipt of neoadjuvant radiation or chemoradiation based on geography. After adjustment for sociodemographic and clinical characteristics, small town/rural radiation patients were significantly less likely to receive IMRT than metropolitan radiation patients (adjusted OR 0.47, 95%CI 0.32-0.67). <h3>Conclusion</h3> Small town/rural Medicare beneficiaries were overall more likely to receive radiation treatment and surgery for their rectal cancer, but less likely to receive IMRT as part of their treatment regimen. The underlying causes for geographic variation in both standard of care surgery with radiation and IMRT utilization warrant further exploration.