Provider Demographics
NPI:1548231210
Name:RUTZ, KEVIN DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:RUTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 88148
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53288-8148
Mailing Address - Country:US
Mailing Address - Phone:314-909-1359
Mailing Address - Fax:314-909-1370
Practice Address - Street 1:2325 DOUGHERTY FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3356
Practice Address - Country:US
Practice Address - Phone:314-909-1359
Practice Address - Fax:314-909-1370
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003002791207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH63665Medicare UPIN