Provider Demographics
NPI:1356415863
Name:RUECKERT, SEBASTIAN A (MD)
Entity type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:A
Last Name:RUECKERT
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 1:901 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3127
Mailing Address - Country:US
Mailing Address - Phone:636-239-8011
Mailing Address - Fax:
Practice Address - Street 1:901 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3127
Practice Address - Country:US
Practice Address - Phone:636-239-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008027335207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093636Medicaid
MO1356415863Medicaid
SR075171OtherCHAMPUS-CHAMPUS
SR075171OtherCOMMERCIAL-COMMERCIAL NUMBER
MI469031210Medicaid
010H262530OtherBLUE CROSS-BLUE CROSS
IL036093636Medicaid
MO147400015Medicare PIN
MO147480013Medicare PIN
SR075171OtherCOMMERCIAL-COMMERCIAL NUMBER