Healthcare Provider Details

I. General information

NPI: 1780637066
Provider Name (Legal Business Name): W SHELBY RUTLEDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: WALLACE SHELBY RUTLEDGE JR. MD

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 PARK AVENUE
ASH FORK AZ
86320-5300
US

IV. Provider business mailing address

PO BOX 3630 NORTH COUNTRY HEALTH CARE
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-637-2305
  • Fax: 928-637-2343
Mailing address:
  • Phone: 928-213-6121
  • Fax: 928-774-6687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19436
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: