Healthcare Provider Details

I. General information

NPI: 1770446221
Provider Name (Legal Business Name): BRAD MICHAEL RUESCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

IV. Provider business mailing address

8117 PRESTON RD STE 800
DALLAS TX
75225-6328
US

V. Phone/Fax

Practice location:
  • Phone: 920-530-4566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number17779-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: