Healthcare Provider Details

I. General information

NPI: 1902893746
Provider Name (Legal Business Name): RUTH C OSBORNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 STADIUM MALL DR
WEST LAFAYETTE IN
47907-2052
US

IV. Provider business mailing address

601 STADIUM MALL DR
WEST LAFAYETTE IN
47907-2052
US

V. Phone/Fax

Practice location:
  • Phone: 765-494-1700
  • Fax: 765-496-1227
Mailing address:
  • Phone: 765-494-1700
  • Fax: 765-496-1227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01038580A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: