Provider Demographics
NPI:1184610255
Name:MAYFORTH, RUTH D (MD)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:D
Last Name:MAYFORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19655
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9655
Mailing Address - Country:US
Mailing Address - Phone:217-545-0702
Mailing Address - Fax:217-545-7305
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:PAV4A
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-0702
Practice Address - Fax:217-545-7305
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361051172086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105117Medicaid
IL256510027Medicare PIN
IL036105117Medicaid