1497763783 NPI number — DR. PAUL GEOFFREY RUTLEDGE MD

Table of content: DR. PAUL GEOFFREY RUTLEDGE MD (NPI 1497763783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497763783 NPI number — DR. PAUL GEOFFREY RUTLEDGE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTLEDGE
Provider First Name:
PAUL
Provider Middle Name:
GEOFFREY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1497763783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23340
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63156-3340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-722-2862
Provider Business Mailing Address Fax Number:
314-722-2852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12812 TESSON FERRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-722-2862
Provider Business Practice Location Address Fax Number:
314-722-2852
Provider Enumeration Date:
08/03/2006

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: 207P00000X , with the licence number:  036-113309 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 036-113309 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2003023209 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 08232205 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 209084607 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0008232163 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036113309 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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