Healthcare Provider Details

I. General information

NPI: 1952831752
Provider Name (Legal Business Name): ERIC STAN RUTKOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 BARD AVENUE DEPARTMENT OF PSYCHIATRY, 1ST FLOOR
STATEN ISLAND NY
10310
US

IV. Provider business mailing address

355 BARD AVENUE DEPARTMENT OF PSYCHIATRY, 1ST FLOOR
STATEN ISLAND NY
10310
US

V. Phone/Fax

Practice location:
  • Phone: 718-818-4121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number25MA11525500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA11525500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: