Basic Information
| Provider Information | |||||||||
| NPI: | 1912930777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSTEN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2605 KENTUCKY AVE | ||||||||
| Address2: | DOB 3, SUITE 601 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704084368 | ||||||||
| FaxNumber: | 2704083272 | ||||||||
| Practice Location | |||||||||
| Address1: | 2605 KENTUCKY AVE | ||||||||
| Address2: | DOB 3, SUITE 601 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704084368 | ||||||||
| FaxNumber: | 2704083272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 39450 | KY | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 64105109 | 05 | KY | MEDICAID | 000000727593 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER |