Provider Demographics
NPI:1811964083
Name:RUTKOWSKI, RICHARD MARK (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MARK
Last Name:RUTKOWSKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-3214
Mailing Address - Country:US
Mailing Address - Phone:845-986-5099
Mailing Address - Fax:845-986-5242
Practice Address - Street 1:214 WEST ST
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-3214
Practice Address - Country:US
Practice Address - Phone:845-986-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0108481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQB3561Medicare PIN
P09207Medicare UPIN