Healthcare Provider Details

I. General information

NPI: 1760986921
Provider Name (Legal Business Name): TAYLOR RUTLEDGE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 N LINCOLN AVE STE B
CHICAGO IL
60657-1108
US

IV. Provider business mailing address

1421 W RASCHER AVE # 1
CHICAGO IL
60640-1205
US

V. Phone/Fax

Practice location:
  • Phone: 312-436-1015
  • Fax:
Mailing address:
  • Phone: 312-436-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number75616-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: