Basic Information
Provider Information | |||||||||
NPI: | 1497736904 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUYLE | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 23340 | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631563340 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149848827 | ||||||||
FaxNumber: | 3149840736 | ||||||||
Practice Location | |||||||||
Address1: | 9930 WATSON RD | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631261827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149848827 | ||||||||
FaxNumber: | 3149840736 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2005 | ||||||||
LastUpdateDate: | 09/28/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2000146142 | MO | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 44925V3431 | 01 | MO | HEALTHCARE USA | OTHER | 144352 | 01 | MO | BCBS | OTHER | 189744 | 01 | MO | GHP | OTHER | 208745703 | 05 | MO |   | MEDICAID | 7614525 | 01 | MO | AETNA | OTHER | 000000010614 | 01 | MO | ESSENCE | OTHER | 036107200 | 05 | IL |   | MEDICAID | 539150 | 01 |   | HEALTHLINK | OTHER | 889862 | 01 | MO | MERCY CARE | OTHER | H62074 | 01 | MO | MERCY | OTHER | 1602596 | 01 | MO | UHC | OTHER |