Healthcare Provider Details

I. General information

NPI: 1558867796
Provider Name (Legal Business Name): LOUIS GRAHAM RUCKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD STE 1800
O FALLON IL
62269-1281
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD STE 1800
O FALLON IL
62269-1281
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-6044
  • Fax: 618-233-5195
Mailing address:
  • Phone: 618-233-6044
  • Fax: 618-233-5195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036181894
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number164375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: