Provider Demographics
NPI:1083828560
Name:RUSK, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:RUSK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:RUSK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:132 ST GEORGES RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2506
Mailing Address - Country:US
Mailing Address - Phone:610-649-6567
Mailing Address - Fax:610-649-2309
Practice Address - Street 1:133 COULTER AVE FL 2
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2410
Practice Address - Country:US
Practice Address - Phone:610-649-7434
Practice Address - Fax:610-649-2309
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD00674E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
019195Medicare UPIN