Basic Information
| Provider Information | |||||||||
| NPI: | 1548282551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUCH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 VILLAGE GREEN CIR SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300803476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703840284 | ||||||||
| FaxNumber: | 7704327638 | ||||||||
| Practice Location | |||||||||
| Address1: | 2193 NORTHLAKE PKWY | ||||||||
| Address2: | STE 114 | ||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300844116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709385974 | ||||||||
| FaxNumber: | 7709397393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 05/20/2008 | ||||||||
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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 | 213E00000X | 407 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 406480290 | 01 | MCR RAILROAD | OTHER | 00115519A | 05 | GA | MEDICAID | 237428 | 01 | BLUE CROSS | OTHER | 518145 | 01 | AETNA | OTHER |