1609962976 NPI number — DR. STEPHEN GERALD RUDIN ED.D.

Table of content: DR. STEPHEN GERALD RUDIN ED.D. (NPI 1609962976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609962976 NPI number — DR. STEPHEN GERALD RUDIN ED.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDIN
Provider First Name:
STEPHEN
Provider Middle Name:
GERALD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED.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:
1609962976
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7301 NW 18TH ST
Provider Second Line Business Mailing Address:
NO. 204
Provider Business Mailing Address City Name:
MARGATE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33063-6857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-970-3205
Provider Business Mailing Address Fax Number:
954-957-7505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1342 BELMONT ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
BROCKTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02301-4436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-427-6911
Provider Business Practice Location Address Fax Number:
508-588-4639
Provider Enumeration Date:
10/05/2006

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: 103TC0700X , with the licence number:  PY-635-PR , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 290594 . This is a "MENTAL HEALTH NETWORK MHN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: W01468 . This is a "BLUE SHIELD OF MASSACHUSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 42279 . This is a "HARVARD PILGRIM HEALTH CA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 732869 . This is a "TUFTS HEALTH PLANS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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