Provider Demographics
NPI:1982470902
Name:RUTH, PRENTICE R (NP)
Entity Type:Individual
Prefix:
First Name:PRENTICE
Middle Name:R
Last Name:RUTH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-963-1300
Practice Address - Fax:317-222-2012
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71014688A363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300084446Medicaid