Provider Demographics
NPI:1285741652
Name:RUTLEDGE SKIN CARE CLINIC, PA
Entity type:Organization
Organization Name:RUTLEDGE SKIN CARE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-564-8300
Mailing Address - Street 1:4801 N BUTLER AVE
Mailing Address - Street 2:SUITE 13101
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6002
Mailing Address - Country:US
Mailing Address - Phone:505-564-8300
Mailing Address - Fax:505-564-8303
Practice Address - Street 1:4 ROAD 3641
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-9562
Practice Address - Country:US
Practice Address - Phone:505-564-8300
Practice Address - Fax:505-564-8303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-338261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA101006Medicare PIN