Provider Demographics
NPI:1437419603
Name:RUGGLE, BRIAN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:RUGGLE
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 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4212 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2737
Practice Address - Country:US
Practice Address - Phone:218-786-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-38413207Q00000X
MN56703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201120340AMedicaid
KS068002326OtherMEDICARE PTAN
P01224928OtherRR MEDICARE
MN1437419603Medicaid
MN080024047Medicare PIN
P01224928OtherRR MEDICARE