Provider Demographics
NPI:1073613444
Name:DE RUYTER, MARTIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:L
Last Name:DE RUYTER
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 1:3901 RAINBOW BLVD
Mailing Address - Street 2:DEPT ANESTHESIOLOGY, MAIL STOP 1034
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160
Mailing Address - Country:US
Mailing Address - Phone:913-588-6670
Mailing Address - Fax:913-588-3365
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:DEPT ANESTHESIOLOGY, MAIL STOP 1034
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160
Practice Address - Country:US
Practice Address - Phone:913-588-6670
Practice Address - Fax:913-588-3365
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30537207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO34101011OtherBCBS KANSAS CITY
MO209352103Medicaid
KS200263180AMedicaid
KS476960OtherFIRSTGUARD
KS476960OtherFIRSTGUARD
617D184AMedicare ID - Type Unspecified
KS200263180AMedicaid