Provider Demographics
NPI:1497724108
Name:KU-RUTH, PHYLLIDIA M (MD)
Entity Type:Individual
Prefix:
First Name:PHYLLIDIA
Middle Name:M
Last Name:KU-RUTH
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 1:100 FODEN RD W
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2319
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 800
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2443
Practice Address - Country:US
Practice Address - Phone:207-774-5816
Practice Address - Fax:207-774-7831
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015348207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2456790OtherAETNA
ME309140099Medicaid
061137OtherANTHEM
061137OtherANTHEM
2456790OtherAETNA
MEMX8619Medicare PIN