Provider Demographics
NPI:1568495380
Name:RUTKOWSKI, MICHAEL DAVID (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:RUTKOWSKI
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 1:5112 WEST TAFT ROAD
Mailing Address - Street 2:SUITE L
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-452-2500
Mailing Address - Fax:315-452-2510
Practice Address - Street 1:104 UNION AVENUE
Practice Address - Street 2:SUITE 806-807
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203
Practice Address - Country:US
Practice Address - Phone:315-474-0542
Practice Address - Fax:315-474-4340
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177347207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01129799Medicaid
NY56601BMedicare PIN
NY51626BMedicare PIN
NY110168489Medicare PIN
NY110147402Medicare PIN
NYC42866Medicare UPIN
NY01129799Medicaid
NY51147HMedicare PIN