Provider Demographics
NPI:1528139714
Name:RUSIN, GRANT M (MD)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:M
Last Name:RUSIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:38508 PLACE RD
Mailing Address - Street 2:
Mailing Address - City:FALL CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97438-9711
Mailing Address - Country:US
Mailing Address - Phone:541-937-1700
Mailing Address - Fax:541-937-1292
Practice Address - Street 1:940 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2208
Practice Address - Country:US
Practice Address - Phone:541-344-2600
Practice Address - Fax:541-344-3317
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22519207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288156Medicaid
OR288156Medicaid
OR109320Medicare ID - Type Unspecified