1881836013 NPI number — DAVID SAMUEL RUDOLPH D.O.

Table of content: (NPI 1922039205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881836013 NPI number — DAVID SAMUEL RUDOLPH D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDOLPH
Provider First Name:
DAVID
Provider Middle Name:
SAMUEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1881836013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 COLLIER RD NW
Provider Second Line Business Mailing Address:
SUITE 4075
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30309-1796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-355-3200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
354 NEWNAN CROSSING BYP
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-2323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-326-4812
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2009

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: 207R00000X , with the licence number:  OS014560 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OS14560 . This is a "PA MEDICAL LICENSE #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1922077643 . This is a "MLHC GROUP NPI #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 440771 . This is a "MLHC MEDICARE AA#" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 824305 . This is a "BS AA#" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 037276 . This is a "MLHC GROUP AA #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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