Provider Demographics
NPI:1508971318
Name:RUSK, ALICE H (MD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:H
Last Name:RUSK
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 1:15 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5205
Mailing Address - Country:US
Mailing Address - Phone:203-863-4490
Mailing Address - Fax:203-863-4496
Practice Address - Street 1:15 VALLEY DRIVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-6074
Practice Address - Country:US
Practice Address - Phone:203-863-4490
Practice Address - Fax:203-863-4496
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035412174400000X, 2084N0400X
CT354122084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G28150Medicare UPIN