Provider Demographics
NPI:1992970628
Name:RUTHSTROM, JACOB B (MD)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:B
Last Name:RUTHSTROM
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:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66201-0716
Mailing Address - Country:US
Mailing Address - Phone:913-642-4900
Mailing Address - Fax:
Practice Address - Street 1:20333 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5350
Practice Address - Country:US
Practice Address - Phone:913-791-4357
Practice Address - Fax:913-381-0979
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0434990207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS9304670OtherAETNA
KS45666017OtherBCBSKC
KS45666017OtherCOVENTRY
MO1992970628Medicaid
KSK54000016Medicare PIN