Healthcare Provider Details

I. General information

NPI: 1881635902
Provider Name (Legal Business Name): DAVID C RUCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MEMORIAL DR
PINEHURST NC
28374-8708
US

IV. Provider business mailing address

PO BOX 843425
BOSTON MA
02284-3425
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-3371
  • Fax: 910-715-2435
Mailing address:
  • Phone: 910-715-3371
  • Fax: 910-715-2435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number9401323
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier891199E
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: