Provider Demographics
NPI:1780637066
Name:RUTLEDGE, W SHELBY (MD)
Entity Type:Individual
Prefix:DR
First Name:W
Middle Name:SHELBY
Last Name:RUTLEDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WALLACE
Other - Middle Name:SHELBY
Other - Last Name:RUTLEDGE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:NORTH COUNTRY HEALTH CARE
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-213-6121
Mailing Address - Fax:928-774-6687
Practice Address - Street 1:112 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:ASH FORK
Practice Address - State:AZ
Practice Address - Zip Code:86320-5300
Practice Address - Country:US
Practice Address - Phone:928-637-2305
Practice Address - Fax:928-637-2343
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109290Medicaid
AZ109290Medicaid
Z122073Medicare PIN
AZF29304Medicare UPIN