Basic Information
| Provider Information | |||||||||
| NPI: | 1073613444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE RUYTER | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 RAINBOW BLVD | ||||||||
| Address2: | DEPT ANESTHESIOLOGY, MAIL STOP 1034 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135886670 | ||||||||
| FaxNumber: | 9135883365 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 RAINBOW BLVD | ||||||||
| Address2: | DEPT ANESTHESIOLOGY, MAIL STOP 1034 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135886670 | ||||||||
| FaxNumber: | 9135883365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 04/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 04-30537 | KS | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 04-30537 | KS | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34101011 | 01 | MO | BCBS KANSAS CITY | OTHER | 209352103 | 05 | MO | MEDICAID | 200263180A | 05 | KS | MEDICAID | 476960 | 01 | KS | FIRSTGUARD | OTHER |