Provider Demographics
NPI:1780770230
Name:RUTMAN, PEGGY A (MD)
Entity type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:A
Last Name:RUTMAN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:318 EAST MAIN STREET
Mailing Address - Street 2:CENTERAL LAKES MEDICAL CLINIC, P.A.
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1645
Mailing Address - Country:US
Mailing Address - Phone:218-546-8375
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:318 EAST MAIN STREET
Practice Address - Street 2:CENTERAL LAKES MEDICAL CLINIC, P.A.
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-8375
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN24127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN434800100Medicaid
MN434800100Medicaid