1679571855 NPI number — DR. RICHARD J IARUSSI M.D.

Table of content: DR. RICHARD J IARUSSI M.D. (NPI 1679571855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679571855 NPI number — DR. RICHARD J IARUSSI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IARUSSI
Provider First Name:
RICHARD
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679571855
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7757 AUBURN RD STE 15
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONCORD TWP
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44077-9604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-350-0832
Provider Business Mailing Address Fax Number:
440-579-0191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 MONCLOVA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAUMEE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43537-1841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-893-5911
Provider Business Practice Location Address Fax Number:
440-579-0191
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  01057869 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 35.050894 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0634817 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 189170N . This is a "INDIANA MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 163857 . This is a "CSHCS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00163010 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 163856 . This is a "CSHCS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200476340 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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