MEDICARE: ALYSSA CAMILLE RUTAN 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	207V00000X	Obstetrics & Gynecology Physician	5797	NE

General Provider Information

NPI Number	:	1790948446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA CAMILLE RUTAN M.D.

Provider Business Mailing Address
First Line	:	1600 S 48TH ST STE 400
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68506-1275
Country	:	US
Telephone Number	:	402-475-8877
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 S 48TH ST STE 400
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68506-1275
Country	:	US
Telephone Number	:	402-475-8877
Fax Number	:

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

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	08/06/2012

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