NPIMap

Individual provider Active NPI

W Shelby Rutledge, M.D.

  • Family Medicine Physician
  • Ash Fork, AZ
National Provider Identifier
1780637066
Registry record updated Oct 22, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
19436 Issued in AZ
Practice address
112 Park Avenue
Ash Fork, AZ 86320-5300
Phone
(928) 637-2305
Fax
(928) 637-2343
NPI assigned
May 18, 2006
Last updated
Oct 22, 2013By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 22, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 19436 AZ Primary

Addresses

Primary practice location

112 Park Avenue
Ash Fork, AZ 86320-5300

Mailing address

PO Box 3630
North Country Health Care
Flagstaff, AZ 86003-3630
Phone (928) 213-6121

Other identifiers 1

IdentifierTypeStateIssuer
109290MedicaidAZ

Other names 1

  • Dr. Wallace Shelby Rutledge Jr. Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Emcare Physician Providers, Inc Past Accepting new patients
Horizon Healthcare Family Medicine Past Accepting new patients
Little Colorado Emergency Physicians LLC Past Accepting new patients
Willard Emergency Physicians Past Accepting new patients
Flagstaff Medical Center Past Accepting new patients
Banner Sun City Medical Group Past Accepting new patients

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147910400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1382400000000",
    "number": "1780637066",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3630",
            "address_2": "NORTH COUNTRY HEALTH CARE",
            "city": "FLAGSTAFF",
            "state": "AZ",
            "postal_code": "860033630",
            "telephone_number": "928-213-6121",
            "fax_number": "928-774-6687"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "112 PARK AVENUE",
            "city": "ASH FORK",
            "state": "AZ",
            "postal_code": "863205300",
            "telephone_number": "928-637-2305",
            "fax_number": "928-637-2343"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RUTLEDGE",
        "first_name": "W",
        "middle_name": "SHELBY",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-18",
        "last_updated": "2013-10-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "AZ",
            "license": "19436",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "109290",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "WALLACE",
            "last_name": "RUTLEDGE",
            "middle_name": "SHELBY",
            "prefix": "DR.",
            "suffix": "JR.",
            "credential": "MD",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Ash Fork, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.