Healthcare Provider Details

I. General information

NPI: 1700455474
Provider Name (Legal Business Name): JACOB JOSEPH RUSK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 SECOR RD
TOLEDO OH
43623-4299
US

IV. Provider business mailing address

4235 SECOR RD
TOLEDO OH
43623-4299
US

V. Phone/Fax

Practice location:
  • Phone: 419-479-5831
  • Fax: 419-479-5799
Mailing address:
  • Phone: 419-473-3561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57.253399
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2021022587
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: