Healthcare Provider Details

I. General information

NPI: 1013301381
Provider Name (Legal Business Name): LAERT RUSHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 FRIENDSHIP ST
NEWPORT RI
02840-2209
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-845-1190
  • Fax: 401-845-1073
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMD17009
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: