Basic Information
| Provider Information | |||||||||
| NPI: | 1316009178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOTHERGILL | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986838004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | 1117 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | FRIDAY HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603782141 | ||||||||
| FaxNumber: | 3603781785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 07/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 49139 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 49139 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207Q00000X | MD60816889 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103440000 | 05 | MN | MEDICAID |