MEDICARE: DR. JOHN MARK RUSCIN PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P1200X	Pharmacotherapy Pharmacist	14645	CO
2	1835P1200X	Pharmacotherapy Pharmacist	051039436	IL

General Provider Information

NPI Number	:	1083695811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN MARK RUSCIN PHARM.D.

Provider Business Mailing Address
First Line	:	805 WILLIAMS BLVD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-2805
Country	:	US
Telephone Number	:	217-753-3895
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 N. FIRST STREET
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62794-9636
Country	:	US
Telephone Number	:	217-545-3934
Fax Number	:	217-545-7127

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	10/07/2008

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