Basic Information
| Provider Information | |||||||||
| NPI: | 1215925789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DARYLE A RUARK MD ORTHOPEDIC SURGEON PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 STAFFORD STREET | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137887321 | ||||||||
| FaxNumber: | 4137336369 | ||||||||
| Practice Location | |||||||||
| Address1: | 299 CAREW ST STE 409 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137887321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | RUARK | ||||||||
| AuthorizedOfficialFirstName: | DARYLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4137887321 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | M12721 | 01 | MA | BLUE CROSS | OTHER | 110067983A | 05 | MA | MEDICAID |