Provider Demographics
NPI:1588602536
Name:RUTT, TINA (NP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:RUTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 PRESTON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4491
Mailing Address - Country:US
Mailing Address - Phone:434-977-3140
Mailing Address - Fax:434-977-4984
Practice Address - Street 1:901 PRESTON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4491
Practice Address - Country:US
Practice Address - Phone:434-977-3140
Practice Address - Fax:434-977-4984
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166364207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010134552Medicaid
VAQ33019Medicare UPIN
VA006352C95Medicare ID - Type UnspecifiedMEDICARE