Provider Demographics
NPI:1477503688
Name:RUTKA, ROBERT THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:THOMAS
Last Name:RUTKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:901 9TH ST N
Mailing Address - Street 2:SUITE 115
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2348
Mailing Address - Country:US
Mailing Address - Phone:218-748-7750
Mailing Address - Fax:218-742-8689
Practice Address - Street 1:901 9TH ST N
Practice Address - Street 2:SUITE 115
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2348
Practice Address - Country:US
Practice Address - Phone:218-748-7750
Practice Address - Fax:218-742-8689
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN27025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN806763500Medicaid
MND75772Medicare UPIN