MEDICARE: RUTH A RUSTAD MD

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	207R00000X	Internal Medicine Physician	38316	MN
2	207N00000X	Dermatology Physician	38316	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110202652	OTHER	MN	RR MEDICARE

General Provider Information

NPI Number	:	1689631038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUTH A RUSTAD MD

Provider Business Mailing Address
First Line	:	4480 CENTERVILLE RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-3674
Country	:	US
Telephone Number	:	651-484-2724
Fax Number	:	651-484-2723

Provider Business Practice Location Address
First Line	:	4480 CENTERVILLE RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-3674
Country	:	US
Telephone Number	:	651-484-2724
Fax Number	:	651-484-2723

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

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	08/01/2012

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Directions to “ RUTH A RUSTAD MD” Practice Location

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