Provider Demographics
NPI:1801184387
Name:GRANT M RUSIN MD PA
Entity Type:Organization
Organization Name:GRANT M RUSIN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-937-1700
Mailing Address - Street 1:38508 PLACE RD
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97438-9711
Mailing Address - Country:US
Mailing Address - Phone:541-937-1700
Mailing Address - Fax:541-937-1292
Practice Address - Street 1:940 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2208
Practice Address - Country:US
Practice Address - Phone:541-344-2600
Practice Address - Fax:541-344-3317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22519207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD18470Medicare UPIN