Individual
DOUGLAS WILLIAM RUSNACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
601 FRONT AVENUE, SUITE #502, COEUR D ALENE, ID 83814
(208) 415-0524
(208) 763-3644
Mailing address
601 FRONT AVENUE, SUITE #502, COEUR D ALENE, ID 83814
(208) 415-0524
(208) 763-3644
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
M9059
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000548198
ANTHEM
KY
05
—
010394856
—
VA
01
—
1019685500001
MEDICAL ASSISTANCE PA
PA
05
—
1019685500001
—
PA
01
—
2501251
MEDICAL ASSISTANCE NY
PA
01
—
2799048
MEDICAL ASSISTANCE OH
PA
05
—
2799048
—
OH
01
—
3425603000
PASSPORT ADVANTAGE
KY
01
—
50017549
PASSPORT
KY
05
—
7100025000
—
KY
01
—
91732
SIHO
KY
Enumeration date
04/06/2006
Last updated
05/27/2009
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