Provider Demographics
NPI:1801950118
Name:RUTBERG, JENNIFER MAIN (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MAIN
Last Name:RUTBERG
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 1:1109 HEPPLEWHITE CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-3821
Mailing Address - Country:US
Mailing Address - Phone:970-810-4700
Mailing Address - Fax:
Practice Address - Street 1:303 COLLAND DR
Practice Address - Street 2:BANNER HEALTH CLINIC
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4205
Practice Address - Country:US
Practice Address - Phone:970-461-8031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0054276207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTAYVN3524Medicare ID - Type Unspecified