Provider Demographics
NPI:1144419532
Name:RUTHERFORD, TONY (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 ROCKY HILL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-8807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 SARTIN DR.
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:KY
Practice Address - Zip Code:42129
Practice Address - Country:US
Practice Address - Phone:270-432-4951
Practice Address - Fax:270-432-5054
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY28004018Medicaid