Provider Demographics
NPI:1043062433
Name:KHALID, RUDABA (PT)
Entity Type:Individual
Prefix:MS
First Name:RUDABA
Middle Name:
Last Name:KHALID
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4188 ASHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-7839
Mailing Address - Country:US
Mailing Address - Phone:618-954-8646
Mailing Address - Fax:
Practice Address - Street 1:2900 FRANK SCOTT PKWY W
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5000
Practice Address - Country:US
Practice Address - Phone:618-607-5103
Practice Address - Fax:618-641-5814
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.027691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist