1326021056 NPI number — MICHAEL S RUDDAT MD

Table of content: MICHAEL S RUDDAT MD (NPI 1326021056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326021056 NPI number — MICHAEL S RUDDAT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDDAT
Provider First Name:
MICHAEL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1326021056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
191 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06042-3556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-646-7704
Provider Business Mailing Address Fax Number:
860-647-7340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 SEYMOUR ST
Provider Second Line Business Practice Location Address:
SUITE 822
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06106-5501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-525-3900
Provider Business Practice Location Address Fax Number:
860-241-8112
Provider Enumeration Date:
11/28/2005

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: 207W00000X , with the licence number:  033808 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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