Provider Demographics
NPI:1174636062
Name:RUGGLES, SCOTT LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:LEWIS
Last Name:RUGGLES
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 1:670 CORMIER ROAD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4824
Mailing Address - Country:US
Mailing Address - Phone:920-494-9685
Mailing Address - Fax:920-494-9687
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-433-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44472208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34209800Medicaid
WI34209800Medicaid
WI000807565Medicare ID - Type Unspecified
WIBR7760526OtherDEA