Provider Demographics
NPI:1316093081
Name:RUSTHOVEN, KYLE EHRMAN (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:EHRMAN
Last Name:RUSTHOVEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1988 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6647
Mailing Address - Country:US
Mailing Address - Phone:910-251-1839
Mailing Address - Fax:910-251-8286
Practice Address - Street 1:2000 NEUSE BOULEVARD
Practice Address - Street 2:CAROLINA EAST MEDICAL CENTER (CANCER CARE)
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3449
Practice Address - Country:US
Practice Address - Phone:252-633-8730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-00402174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC160N2OtherBLUE CROSS/BLUE SHIELD
NC5915503Medicaid
NC5915503Medicaid