Provider Demographics
NPI:1043778012
Name:RUDY, ZACHERY M
Entity Type:Individual
Prefix:
First Name:ZACHERY
Middle Name:M
Last Name:RUDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 MANNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ELLIOTTSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17024-8923
Mailing Address - Country:US
Mailing Address - Phone:717-636-9641
Mailing Address - Fax:
Practice Address - Street 1:2909 MANNSVILLE RD
Practice Address - Street 2:
Practice Address - City:ELLIOTTSBURG
Practice Address - State:PA
Practice Address - Zip Code:17024-8923
Practice Address - Country:US
Practice Address - Phone:717-636-9641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAYWP80113775302OtherCAPITAL BLUE CROSS