Healthcare Provider Details

I. General information

NPI: 1417513532
Provider Name (Legal Business Name): ROBERT E. RUST MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N DIVISION AVE
SANDPOINT ID
83864-8268
US

IV. Provider business mailing address

1301 N DIVISION AVE
SANDPOINT ID
83864-8268
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1345
  • Fax: 208-255-5531
Mailing address:
  • Phone: 208-263-1345
  • Fax: 208-255-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT E RUST
Title or Position: PROVIDER
Credential: MD, ABAM, FASAM
Phone: 208-290-3567