Provider Demographics
NPI:1932128246
Name:RUTKOSKI, PAMELA HELLERMAN (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:HELLERMAN
Last Name:RUTKOSKI
Suffix:
Gender:F
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:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:AVIS
Mailing Address - State:PA
Mailing Address - Zip Code:17721-0430
Mailing Address - Country:US
Mailing Address - Phone:570-398-5195
Mailing Address - Fax:570-873-3177
Practice Address - Street 1:990 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:JERSEY SHORE
Practice Address - State:PA
Practice Address - Zip Code:17740-1727
Practice Address - Country:US
Practice Address - Phone:570-398-2600
Practice Address - Fax:570-398-2055
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034656E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA118438707OtherDEPARTMENT OF LABOR
PA232809429OtherTRICARE
PA080154392OtherRAILROAD MEDICARE
PA101876215 0002Medicaid
PA03232501OtherCAPITAL BLUE CROSS
PA487654OtherBLUE SHIELD
PA70209C245OtherGEISINGER
PA03232501OtherKEYSTONE
PAB42266OtherHEALTH AMERICA
PAB42266Medicare UPIN
PA487654Medicare ID - Type Unspecified