1962939942 NPI number — CHANTEL M RUSZ NP

Table of content: CHANTEL M RUSZ NP (NPI 1962939942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962939942 NPI number — CHANTEL M RUSZ NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSZ
Provider First Name:
CHANTEL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1962939942
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4243 NW FEDERAL HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JENSEN BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34957-3600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-735-1178
Provider Business Mailing Address Fax Number:
772-223-6354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4243 NW FEDERAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JENSEN BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34957-3600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-735-1178
Provider Business Practice Location Address Fax Number:
772-223-6354
Provider Enumeration Date:
05/22/2017

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: 363LP0808X , with the licence number:  APRN11000792 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103739000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".