Basic Information
| Provider Information | |||||||||
| NPI: | 1952356503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUTCHIK | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2968 | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465152968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963200 | ||||||||
| FaxNumber: | 5742963392 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 PARK PL STE B | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465453557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5748555800 | ||||||||
| FaxNumber: | 5748555805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 09/04/2008 | ||||||||
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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 | 208800000X | 01057389 | IN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200443540 | 05 | IN | MEDICAID | P00038154 | 01 | IN | MEDICARE RAILROAD | OTHER | 021236800 | 01 | IN | FEDERAL BLACK LUNG | OTHER |