MEDICARE: MR. JOHN CHRISTIAN RUTLEDGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	497665	NY

General Provider Information

NPI Number	:	1366078008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN CHRISTIAN RUTLEDGE

Provider Business Mailing Address
First Line	:	432 LAKE POINTE DR.
Second Line	:	PRIVATE
City	:	MIDDLE ISLAND
State	:	NY
Zip	:	11953
Country	:	US
Telephone Number	:	631-223-6739
Fax Number	:

Provider Business Practice Location Address
First Line	:	432 LAKE POINTE DR
Second Line	:
City	:	MIDDLE ISLAND
State	:	NY
Zip	:	11953-2033
Country	:	US
Telephone Number	:	631-223-6739
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2020
Last Update Date	:	03/13/2020

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