Provider Demographics
NPI:1336101005
Name:RUSNACK, DOUGLAS WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:RUSNACK
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 1:601 FRONT AVENUE
Mailing Address - Street 2:SUITE #502
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-415-0524
Mailing Address - Fax:208-763-3644
Practice Address - Street 1:601 FRONT AVENUE
Practice Address - Street 2:SUITE #502
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-415-0524
Practice Address - Fax:208-763-3644
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM90592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010394856Medicaid
PA2799048OtherMEDICAL ASSISTANCE OH
KY50017549OtherPASSPORT
PA1019685500001OtherMEDICAL ASSISTANCE PA
OH2799048Medicaid
KY000000548198OtherANTHEM
PA1019685500001Medicaid
PA2501251OtherMEDICAL ASSISTANCE NY
KY3425603000OtherPASSPORT ADVANTAGE
KY7100025000Medicaid
KY91732OtherSIHO
PA2799048OtherMEDICAL ASSISTANCE OH
PA115248Medicare PIN
PA1019685500001Medicaid
OH2799048Medicaid
KY0998888Medicare PIN
PA2501251OtherMEDICAL ASSISTANCE NY
VA010394856Medicaid