Healthcare Provider Details

I. General information

NPI: 1003907155
Provider Name (Legal Business Name): WALTER KENNETH RUSH IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 4TH ST E
SAINT PAUL MN
55101-1696
US

IV. Provider business mailing address

275 4TH ST E
SAINT PAUL MN
55101-1696
US

V. Phone/Fax

Practice location:
  • Phone: 651-389-4690
  • Fax: 651-389-4691
Mailing address:
  • Phone: 651-389-4690
  • Fax: 651-389-4691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number45379
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: