1780637066 NPI number — DR. W SHELBY RUTLEDGE M.D.

Table of content: DR. W SHELBY RUTLEDGE M.D. (NPI 1780637066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780637066 NPI number — DR. W SHELBY RUTLEDGE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTLEDGE
Provider First Name:
W
Provider Middle Name:
SHELBY
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:
RUTLEDGE
Provider Other First Name:
WALLACE
Provider Other Middle Name:
SHELBY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1780637066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3630
Provider Second Line Business Mailing Address:
NORTH COUNTRY HEALTH CARE
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86003-3630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-213-6121
Provider Business Mailing Address Fax Number:
928-774-6687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 PARK AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASH FORK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86320-5300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-637-2305
Provider Business Practice Location Address Fax Number:
928-637-2343
Provider Enumeration Date:
05/18/2006

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: 207Q00000X , with the licence number:  19436 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 109290 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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