Provider Demographics
NPI:1881640043
Name:RUSCH, MARK D (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:RUSCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPT OF PLASTIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5476
Mailing Address - Fax:414-805-5850
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPT OF PLASTIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5476
Practice Address - Fax:414-805-5850
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1105103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000105OtherHUMANA
WI1881640043Medicaid
S16405Medicare UPIN
WI090H73601Medicare PIN