Provider Demographics
NPI:1104824135
Name:RUDA, SUSAN C (RN,MS,APN,ONC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:RUDA
Suffix:
Gender:F
Credentials:RN,MS,APN,ONC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 W COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1001
Mailing Address - Country:US
Mailing Address - Phone:708-361-0600
Mailing Address - Fax:708-923-2529
Practice Address - Street 1:7600 W COLLEGE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1001
Practice Address - Country:US
Practice Address - Phone:708-361-0600
Practice Address - Fax:708-923-2529
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ08534Medicare UPIN
ILK34956Medicare PIN