Provider Demographics
NPI:1174735302
Name:RUETER, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RUETER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 NE MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3786
Mailing Address - Country:US
Mailing Address - Phone:541-318-4249
Mailing Address - Fax:541-278-8377
Practice Address - Street 1:1247 NE MEDICAL CENTER DR
Practice Address - Street 2:SUITE 3
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3786
Practice Address - Country:US
Practice Address - Phone:541-318-4249
Practice Address - Fax:541-278-8377
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-049880207Q00000X
ORMD28648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500605395Medicaid
OR500605395Medicaid
1174735302Medicare UPIN