Healthcare Provider Details

I. General information

NPI: 1174629836
Provider Name (Legal Business Name): ANDREW D. RUTHBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 1017
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

1725 W HARRISON ST SUITE 1017
CHICAGO IL
60612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-6641
  • Fax: 312-563-2075
Mailing address:
  • Phone: 312-942-6641
  • Fax: 312-563-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number49505
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number036.121932
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: