Basic Information
| Provider Information | |||||||||
| NPI: | 1174735302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUETER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1247 NE MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977013786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413184249 | ||||||||
| FaxNumber: | 5412788377 | ||||||||
| Practice Location | |||||||||
| Address1: | 1247 NE MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977013786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413184249 | ||||||||
| FaxNumber: | 5412788377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 08/20/2012 | ||||||||
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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 | 207Q00000X | 125-049880 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD28648 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500605395 | 05 | OR | MEDICAID |