Provider Demographics
NPI:1316009178
Name:FOTHERGILL, RUTH KAY (MD,)
Entity Type:Individual
Prefix:DR
First Name:RUTH
Middle Name:KAY
Last Name:FOTHERGILL
Suffix:
Gender:F
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:1117 SPRING ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250
Practice Address - Country:US
Practice Address - Phone:360-378-2141
Practice Address - Fax:360-378-1785
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49139207Q00000X, 207QG0300X
WAMD60816889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103440000Medicaid
MNFO2485Medicare UPIN
ILFO2485Medicare UPIN