MEDICARE: DR. RALPH H. RUCKLE M.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	207Q00000X	Family Medicine Physician	MD9576	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2000371	OTHER	TN	BCBS OF TENNESSEE

General Provider Information

NPI Number	:	1790770378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RALPH H. RUCKLE M.D.

Provider Business Mailing Address
First Line	:	103 REDBUD DR
Second Line	:	SUITE C
City	:	PORTLAND
State	:	TN
Zip	:	37148-1617
Country	:	US
Telephone Number	:	615-325-7337
Fax Number	:	615-325-0164

Provider Business Practice Location Address
First Line	:	103 REDBUD DR
Second Line	:	SUITE C
City	:	PORTLAND
State	:	TN
Zip	:	37148-1617
Country	:	US
Telephone Number	:	615-325-7337
Fax Number	:	615-325-0164

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	07/08/2007

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