Provider Demographics
NPI:1497763783
Name:RUTLEDGE, PAUL GEOFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:GEOFFREY
Last Name:RUTLEDGE
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:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-722-2862
Mailing Address - Fax:314-722-2852
Practice Address - Street 1:12812 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2913
Practice Address - Country:US
Practice Address - Phone:314-722-2862
Practice Address - Fax:314-722-2852
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113309207P00000X, 207Q00000X
MO2003023209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08232205OtherBLUE CROSS BLUE SHIELD
MO209084607Medicaid
IL0008232163OtherBLUECROSS BLUESHIELD
IL036113309Medicaid
IL08232205OtherBLUE CROSS BLUE SHIELD
MO124510093Medicare PIN
MOI14322Medicare UPIN
IL0008232163OtherBLUECROSS BLUESHIELD
IL036113309Medicaid
ILK30292Medicare PIN