Provider Demographics
NPI:1255521563
Name:RUSNAK, MICHAEL P (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:RUSNAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E PROSPECT ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9773
Mailing Address - Country:US
Mailing Address - Phone:970-493-0112
Mailing Address - Fax:
Practice Address - Street 1:2500 E PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9773
Practice Address - Country:US
Practice Address - Phone:970-493-0112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0046798207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1255521563Medicaid
COP00645247OtherRR MEDICARE
CO98508806Medicaid
COP00645247OtherRR MEDICARE
AL051559736Medicare PIN
COCO300944Medicare PIN
WY1255521563Medicaid
AL051559736Medicare PIN
COCO300944Medicare PIN