Healthcare Provider Details

I. General information

NPI: 1750340808
Provider Name (Legal Business Name): RICHARD DOUGLAS RUCKER JR. MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 MIDDLE ST
FALL RIVER MA
02721-1733
US

IV. Provider business mailing address

795 MIDDLE ST
FALL RIVER MA
02721-1733
US

V. Phone/Fax

Practice location:
  • Phone: 508-674-5600
  • Fax: 508-675-5611
Mailing address:
  • Phone: 508-674-5600
  • Fax: 508-675-5611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number23186
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number58164
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier58164
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMASSACHUSETTS LICENSE
# 2
Identifier23186
Identifier TypeOTHER
Identifier State
Identifier IssuerMN MEDICAL LICENSE
# 3
Identifier993565700
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: