1215996004 NPI number — MRS. DIANNE RUSCOE NP

Table of content: MRS. DIANNE RUSCOE NP (NPI 1215996004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215996004 NPI number — MRS. DIANNE RUSCOE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSCOE
Provider First Name:
DIANNE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1215996004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1410
Provider Second Line Business Mailing Address:
ATTN: CLINIC ADMINISTRATION
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38935-1410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-459-7189
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 STRONG AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38930-4035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-459-7030
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2006

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: 363LP0200X , with the licence number:  RN93020 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00114504 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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