Basic Information
Provider Information | |||||||||
NPI: | 1710079835 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUTLAND | ||||||||
FirstName: | BETH | ||||||||
MiddleName: | MILLER | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40480 | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366400480 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514705842 | ||||||||
FaxNumber: | 2514705809 | ||||||||
Practice Location | |||||||||
Address1: | 2451 FILLINGIM ST | ||||||||
Address2: | MASTIN 617 | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366172238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514717790 | ||||||||
FaxNumber: | 2514717715 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2006 | ||||||||
LastUpdateDate: | 09/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 26417 | AL | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 009913240 | 05 | AL |   | MEDICAID | 01200018 | 05 | MS |   | MEDICAID | 100552 | 05 | AL |   | MEDICAID | 51545954 | 01 | AL | BC BS | OTHER | 51545686 | 01 | AL | BCBS-2451 FILLINGIM ST | OTHER | 100555 | 05 | AL |   | MEDICAID | 100553 | 05 | AL |   | MEDICAID | 51545955 | 01 | AL | BC BS | OTHER | 51545953 | 01 | AL | BC BS | OTHER |