Provider Demographics
NPI:1083274054
Name:RUDMAN, MICHELLE DIANE (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:DIANE
Last Name:RUDMAN
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-1408
Mailing Address - Fax:314-286-1985
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV NEUROLOGY AGING AND DEMENTIA, STE 6C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-1408
Practice Address - Fax:314-286-1985
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20230226682084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200086424Medicaid