Healthcare Provider Details

I. General information

NPI: 1477503688
Provider Name (Legal Business Name): ROBERT THOMAS RUTKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 9TH ST N SUITE 115
VIRGINIA MN
55792-2348
US

IV. Provider business mailing address

901 9TH ST N SUITE 115
VIRGINIA MN
55792-2348
US

V. Phone/Fax

Practice location:
  • Phone: 218-748-7750
  • Fax: 218-742-8689
Mailing address:
  • Phone: 218-748-7750
  • Fax: 218-742-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27025
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: