Provider Demographics
NPI:1336144401
Name:JOHNSRUDE, CHRISTOPHER LARS (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:LARS
Last Name:JOHNSRUDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:411 E CHESTNUT ST # 5A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-7450
Practice Address - Fax:502-588-7728
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-02-10
Deactivation Date:2022-01-30
Deactivation Code:
Reactivation Date:2022-02-10
Provider Licenses
StateLicense IDTaxonomies
KY37041207RC0001X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200114610AMedicaid
KY64047947Medicaid
IN200114610AMedicaid
KYG10763Medicare UPIN
KY64047947Medicaid