Basic Information
Provider Information | |||||||||
NPI: | 1497950406 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUTSCH | ||||||||
FirstName: | CHRISTINA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MAZURCZAK | ||||||||
OtherFirstName: | CHRISTINA | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1700 W PARADISE DR | ||||||||
Address2: |   | ||||||||
City: | WEST BEND | ||||||||
State: | WI | ||||||||
PostalCode: | 530959795 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2623343451 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | W225N16711 CEDAR PARK CT | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | WI | ||||||||
PostalCode: | 530379222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2626771101 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2007 | ||||||||
LastUpdateDate: | 04/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 52911 | WI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.