Healthcare Provider Details

I. General information

NPI: 1659770576
Provider Name (Legal Business Name): SUSAN MICHELLE RUGH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 BENNETT AVE
MEDFORD OR
97504-6715
US

IV. Provider business mailing address

825 BENNETT AVE
MEDFORD OR
97504-6715
US

V. Phone/Fax

Practice location:
  • Phone: 541-608-1996
  • Fax: 541-772-1533
Mailing address:
  • Phone: 541-608-1996
  • Fax: 541-772-1533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201907059
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: