Basic Information
| Provider Information | |||||||||
| NPI: | 1255521563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSNAK | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 E PROSPECT ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704930112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 E PROSPECT RD | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704930112 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0801X | DR.0046798 | CO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | 1255521563 | 05 | WY | MEDICAID | P00645247 | 01 | CO | RR MEDICARE | OTHER | 98508806 | 05 | CO | MEDICAID |