Provider Demographics
NPI:1023041613
Name:RUTKOWSKI, THADDEUS C (MD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:C
Last Name:RUTKOWSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 LINWOOD AVE REAR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1629
Mailing Address - Country:US
Mailing Address - Phone:716-886-0444
Mailing Address - Fax:716-885-7070
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-859-2220
Practice Address - Fax:716-859-1521
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152995207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00773799Medicaid
L22125Medicare ID - Type Unspecified
NY00773799Medicaid