Provider Demographics
NPI:1073608568
Name:RUOFF, GARY STEPHEN (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:STEPHEN
Last Name:RUOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 SOUTH GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686
Mailing Address - Country:US
Mailing Address - Phone:231-935-0580
Mailing Address - Fax:231-935-0584
Practice Address - Street 1:201 SOUTH GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-935-0580
Practice Address - Fax:231-935-0584
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013402207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383559647OtherTAX ID
MI27136OtherPRIORITY HEALTH PAYER COD
MI4321711Medicaid
MI5280086OtherBLUE CROSS BLUE SHIELD
MIH13875Medicare UPIN
MI0N32540Medicare PIN