Healthcare Provider Details

I. General information

NPI: 1497950406
Provider Name (Legal Business Name): CHRISTINA MARIE RUTSCH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA MARIE MAZURCZAK M.D.

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W225N16711 CEDAR PARK CT
JACKSON WI
53037-9222
US

IV. Provider business mailing address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

V. Phone/Fax

Practice location:
  • Phone: 262-677-1101
  • Fax:
Mailing address:
  • Phone: 262-334-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number52911
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: