Provider Demographics
NPI:1407822612
Name:RUDNICK, LAURIE JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:JEAN
Last Name:RUDNICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:JEAN
Other - Last Name:BURGOYNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:19901 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1069
Mailing Address - Country:US
Mailing Address - Phone:586-777-1277
Mailing Address - Fax:586-777-0106
Practice Address - Street 1:19901 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1069
Practice Address - Country:US
Practice Address - Phone:586-777-1277
Practice Address - Fax:586-777-0106
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P27380OtherMEDICARE GROUP LEGACY #
MI700E031610OtherBCBS GROUP NUMBER
MI4828442Medicaid
MI0P27380OtherMEDICARE GROUP LEGACY #
MI4828442Medicaid
H50176Medicare UPIN
MI700E031610OtherBCBS GROUP NUMBER