Provider Demographics
NPI:1235622432
Name:JENA RUD, MARIE DANIELLE (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:DANIELLE
Last Name:JENA RUD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:DANIELLE
Other - Last Name:JENA RUD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 726721
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6721
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:4417 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1923
Practice Address - Country:US
Practice Address - Phone:773-377-7736
Practice Address - Fax:815-642-5723
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.155555207Q00000X
IL125.072985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine