Healthcare Provider Details

I. General information

NPI: 1922275643
Provider Name (Legal Business Name): MARY C RUSNAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

14543 COTSWOLD LN
CARMEL IN
46033-9182
US

V. Phone/Fax

Practice location:
  • Phone: 317-988-2102
  • Fax:
Mailing address:
  • Phone: 317-581-8909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28095026A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: