Provider Demographics
NPI:1811967573
Name:RUTKOWSKI, MARY (DC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RUTKOWSKI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5419 ROUTE 309
Mailing Address - Street 2:
Mailing Address - City:CENTER VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18034-9601
Mailing Address - Country:US
Mailing Address - Phone:610-282-1722
Mailing Address - Fax:610-282-0101
Practice Address - Street 1:5419 ROUTE 309
Practice Address - Street 2:
Practice Address - City:CENTER VALLEY
Practice Address - State:PA
Practice Address - Zip Code:18034-9601
Practice Address - Country:US
Practice Address - Phone:610-282-1722
Practice Address - Fax:610-282-0101
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC3752-L111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02691000OtherCBC- CHIROPRACTOR
PA02691000OtherCBC- CHIROPRACTOR
PAT72800Medicare UPIN