Healthcare Provider Details

I. General information

NPI: 1104780279
Provider Name (Legal Business Name): PHIL RUTLEDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5402 BUS 50 W UNIT 1
JEFFERSON CITY MO
65109
US

IV. Provider business mailing address

5402 BUS 50 W UNIT 1
JEFFERSON CITY MO
65109
US

V. Phone/Fax

Practice location:
  • Phone: 573-284-1776
  • Fax:
Mailing address:
  • Phone: 573-284-1776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number2020027391
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: