Basic Information
| Provider Information | |||||||||
| NPI: | 1124093943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUTH | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | ROY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
| FaxNumber: | 2172772253 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 COLLEGE AVE | ||||||||
| Address2: | STE 2 | ||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172283377 | ||||||||
| FaxNumber: | 2172282657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 036068434 | IL | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | R7A18 | MO | N | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 036068434 | 05 | IL | MEDICAID |