1124175435 NPI number — MRS. MARILYNN ELIZABETH RUDOLPH RRT, AE-C

Table of content: MRS. MARILYNN ELIZABETH RUDOLPH RRT, AE-C (NPI 1124175435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124175435 NPI number — MRS. MARILYNN ELIZABETH RUDOLPH RRT, AE-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDOLPH
Provider First Name:
MARILYNN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RRT, AE-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124175435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10569 QUINCY BLVD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAINE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55434-2721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-717-1564
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14500 99TH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369-4730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-898-1117
Provider Business Practice Location Address Fax Number:
763-898-1061
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2279P1006X , with the licence number:  1275 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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