=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497724108
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHYLLIDIA M. KU-RUTH MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 03/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 84 MARGINAL WAY SUITE 800
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-774-5816
-----------------------------------------------------
Fax | 207-774-7831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 FODEN RD W SUITE 203
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-828-0361
-----------------------------------------------------
Fax | 207-874-1483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 015348
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------