Provider Demographics
NPI:1073602520
Name:RUTKOWSKI, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
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 1:4400 ROCKSIDE RD
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2109
Mailing Address - Country:US
Mailing Address - Phone:216-573-1300
Mailing Address - Fax:
Practice Address - Street 1:4400 ROCKSIDE RD
Practice Address - Street 2:SUITE 2100
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2109
Practice Address - Country:US
Practice Address - Phone:216-573-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-088270207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000590092OtherANTHEM BLUE SHIELD
OHT88270OtherSUMMACARE
OH2698540Medicaid
OH000000500020OtherANTHEM
OH745390OtherBUCKEYE
I62047Medicare UPIN
OH4193861Medicare PIN
OH000000500020OtherANTHEM
OH745390OtherBUCKEYE
OH4193862Medicare PIN