Provider Demographics
NPI:1114973013
Name:RUCKER, PATRICK T (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:T
Last Name:RUCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2055 NORMANDIE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-2732
Mailing Address - Country:US
Mailing Address - Phone:334-269-6337
Mailing Address - Fax:334-834-0657
Practice Address - Street 1:4145 CARMICHAEL RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2803
Practice Address - Country:US
Practice Address - Phone:334-273-2320
Practice Address - Fax:334-273-2386
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ314362085R0202X
ALMD274762085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G78752Medicare UPIN
051551742Medicare PIN