Healthcare Provider Details

I. General information

NPI: 1548231210
Provider Name (Legal Business Name): KEVIN DOUGLAS RUTZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 DOUGHERTY FERRY RD STE 100
SAINT LOUIS MO
63122-3356
US

IV. Provider business mailing address

PO BOX 88148
MILWAUKEE WI
53288-8148
US

V. Phone/Fax

Practice location:
  • Phone: 314-909-1359
  • Fax: 314-909-1370
Mailing address:
  • Phone: 314-909-1359
  • Fax: 314-909-1370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2003002791
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: