=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548282551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN A RUCH DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2193 NORTHLAKE PKWY STE 114
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-938-5974
-----------------------------------------------------
Fax | 770-939-7393
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 VILLAGE GREEN CIR SE SUITE 200
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-3476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-384-0284
-----------------------------------------------------
Fax | 770-432-7638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 407
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------