Healthcare Provider Details

I. General information

NPI: 1528139714
Provider Name (Legal Business Name): GRANT M RUSIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 COUNTRY CLUB RD
EUGENE OR
97401-2208
US

IV. Provider business mailing address

38508 PLACE RD
FALL CREEK OR
97438-9711
US

V. Phone/Fax

Practice location:
  • Phone: 541-344-2600
  • Fax: 541-344-3317
Mailing address:
  • Phone: 541-937-1700
  • Fax: 541-937-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD22519
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier288156
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: