Healthcare Provider Details

I. General information

NPI: 1750743050
Provider Name (Legal Business Name): JUSTIN ADAM RUECKERT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-2200
US

IV. Provider business mailing address

6708 PENNS CHAPEL RD
BOWLING GREEN KY
42101-7000
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-1446
  • Fax: 859-257-7572
Mailing address:
  • Phone: 801-707-6354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number04988
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number04988
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: