Provider Demographics
NPI:1033377882
Name:BENJAMIN L. RUCKER M.D. P.C.
Entity Type:Organization
Organization Name:BENJAMIN L. RUCKER M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT/ OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-733-9447
Mailing Address - Street 1:1138 DRUID PARK AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5850
Mailing Address - Country:US
Mailing Address - Phone:706-733-9447
Mailing Address - Fax:706-738-0863
Practice Address - Street 1:1138 DRUID PARK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5850
Practice Address - Country:US
Practice Address - Phone:706-733-9447
Practice Address - Fax:706-738-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017877207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG17877Medicaid
010270OtherBCBS
GA000153139-BMedicaid
255780226DMedicare PIN
GA000153139-BMedicaid