1457362717 NPI number — RHYS RUDOLPH M.D.

Table of content: RHYS RUDOLPH M.D. (NPI 1457362717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457362717 NPI number — RHYS RUDOLPH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDOLPH
Provider First Name:
RHYS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1457362717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1234 E DUPONT RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-373-9700
Provider Business Mailing Address Fax Number:
260-373-9740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 CAREW ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-4788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-482-8681
Provider Business Practice Location Address Fax Number:
260-373-4699
Provider Enumeration Date:
08/11/2006

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: 208800000X , with the licence number:  01029545 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100338370 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000633802 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00803483 . This is a "R.R. MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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