1053620344 NPI number — ALYSSA MAUREEN RUTHERFORD PA-C

Table of content: ALYSSA MAUREEN RUTHERFORD PA-C (NPI 1053620344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053620344 NPI number — ALYSSA MAUREEN RUTHERFORD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUTHERFORD
Provider First Name:
ALYSSA
Provider Middle Name:
MAUREEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AUBRY
Provider Other First Name:
ALYSSA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053620344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 S STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48108-1633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-647-5299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 E MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48109-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-936-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  5601005725 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 830N84 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 217915201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".