Healthcare Provider Details

I. General information

NPI: 1164168043
Provider Name (Legal Business Name): AMI RUTH OGDEN RSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 N ILLINOIS ROUTE 3
WATERLOO IL
62298-1059
US

IV. Provider business mailing address

PO BOX 146
WATERLOO IL
62298-0146
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: