Basic Information
| Provider Information | |||||||||
| NPI: | 1689624868 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUSTICO B. ORTIZ, M.D.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3150 HALLMARK CT | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486032173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897934420 | ||||||||
| FaxNumber: | 9897938577 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 HALLMARK CT | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486032173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897934420 | ||||||||
| FaxNumber: | 9897938577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ORTIZ | ||||||||
| AuthorizedOfficialFirstName: | RUSTICO | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9897934420 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | RO032199 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1036714 | 05 | MI | MEDICAID | 1107398752 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |